Executive Times






2006 Book Reviews


LBJ by Randall Woods




(Highly Recommended)




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I’ll admit to a multi-decade fascination with the character of Lyndon Baines Johnson as a disclaimer that influenced by high rating for Randall Woods’ new biography of Johnson titled, LBJ: Architect of American Ambition. In so many ways, LBJ was larger than life, and possibly as complicated a person as any human could be. Some prior biographies have stressed his weaknesses, and the prominence of the Vietnam War in his legacy. Woods treatment comes across as more balanced, and more open to understanding Johnson in his fullness. Here’s an excerpt, from the end of Chapter 27, “A New Bill of Rights,” pp. 568-573:


Again, Johnson chose a general program to help build broad support for the Great Society as a whole. The next jewel in the diadem would be Medicare, a system of health insurance for elderly Americans. Of all the advanced industrial democracies in the 1960s, only the United States did not have in place a government program to protect the elderly from the often catastrophic costs of health care. Britain, France, Sweden, and Denmark all boasted either a nationalized health system or national health insurance. There were no federally or state-supported nursing homes, no help for aged Americans afflicted with cancer, di­abetes, heart disease, and stroke who did not have private means. In 1934, FDR had suggested including a program of national health insurance in the Social Se­curity Act but had backed off in the face of opposition from the American Med­ical Association. In 1939, liberal Democrats had sponsored legislation to create a system of national health insurance, but it had gotten nowhere. Harry Truman included plans for a national health insurance program in the Fair Deal, but Robert Taft and the conservative coalition sided with the AMA and private in­surance companies, and the man from Missouri was stymied. 52

In 1959, George Reedy had warned his boss that the absence of government. supported health care for the aged was a national disgrace and would only get worse. “In 1900,” he noted, “there were three million people in this country over sixty-five. Today, the number is close to fifteen million, and in ten years there will be about twenty-one million.. . Somehow, the problem must be dramatized in some way so that Americans will know that the problem of the aging amounts to a collective responsibility. America is no longer a nation of simple pioneer folk in which grandmother and grandfather can spend their de­clining years in a log cabin doing odd jobs and taking care of the grandchil­dren.”53 LBJ was innately empathetic with the afflicted, particular those who were dependent. Memories of his paralyzed and wheelchair-ridden grand­mother who had had to live with him and his family still haunted him. More than this, however, LBJ wanted to define health care—like education, a healthy diet, and adequate shelter—as a basic right. He remembered discussing educa­tion and the Constitution in a college theme; he received an F, he recalled. The Constitution said nothing about education—or health care. But they were im­plied, Johnson would insist. Like trial by jury and freedom of speech, he told aide Harry Middleton, adequate health care ought to be a federal guarantee: “A person who comes into birth in this country ought to have those rights, what­ever the price is.”54 In November 1964, on the eve of the election, when a re­porter asked if a health insurance bill for the aged would be a priority if he were elected, LBJ replied, “Just top of the list.” 55

In 1961, JFK had asked Wilbur Cohen, long-time administrator of the origi­nal Social Security System, who was then teaching at the University of Michi­gan, to head his task force on health and Social Security. What Cohen and his colleagues came up with was a scheme of contributory medical insurance for the nearly 14.8 million Americans receiving Old-Age Survivors and Disability Insurance—Social Security. The AMA responded by launching the biggest and costliest lobbying campaign in American history Seventy publicists toiled away at the organization’s Chicago office, and no fewer then twenty-three lobbyists patroled Capitol Hill. The AMA spent more than $50 million on the effort. In their campaign, doctors were ably and liberally assisted by the private insurance industry While they eyed their incomes and profit statements nervously, physi­cians and insurance executives cried that Medicare would undermine individ­ual initiative and open the door to socialized medicine, another fateful step in the liberal drive to convert America into a welfare state. The third roadblock in Medicare’s path was Congressman Wilbur Mills (D-Arkansas), chair of the powerful House Ways and Means Committee, who opposed the legislation for his own reasons. Thus was Medicare still languishing when LBJ came to the presidency that day in late November 1963.

Mills was a stocky man of average height, noted, like Robert McNamara, for his slicked-back hair and steel-rimmed glasses. He was the son of a small-town merchant and had attended Hendrix College, where he so excelled in his stud­ies that he was able to gain entry to Harvard Law School. In 1934 he was admit­ted to the Arkansas Bar and four years later was elected to Congress to represent the Second District, which included the Ozark Mountain region in the north­west, an area of small farms in the north-central part of the state, and the Missis­sippi Delta to the east. His district was poor and thinly populated. Labor unions were virtually nonexistent. 56 Sam Rayburn took young Mills under his wing, taught him the traditions and procedures of the House, and helped him land a seat on Ways and Means. The Arkansan was not a reactionary but a conservative New Dealer. Despite representing a region that clung tenaciously to the nine­teenth century Mills believed that in a modern society, order and justice re­quired that the federal government play an active role, protecting the defenseless, regulating the economy, and guarding the nation’s security. “Do not be misled,” he said in 1948, “economic policies of Government both at home and in international relations determine to a great extent these periods of prosperity and depression.57 Yet Mills was obsessed with maintaining the fiscal integrity of existing government programs, especially Social Security. “In the Social Security field,” Wilbur Cohen observed, “Mr. Mills is probably the only man out of the five hundred and thirty five people in Congress who. . . is com­pletely conversant with the basis for making the actuarial estimates and all of the factors that enter into it.58 Mills was not opposed to the notion of health care for the aged, but he believed that the proposal under consideration would dis­credit and/or bankrupt Social Security. Existing benefits under Social Security were cash payments based on payroll deductions and employer contributions. These payments could be predicted and controlled. Under the existing Medicare proposal, Social Security was to pay for medical services the cost of which could neither be predicted nor controlled. Experts told him that the most workers would agree to have withheld from their paychecks without rebelling was 10 percent. Mills could see Medicare producing costs that would spin out of control.

Throughout 1964, Wilbur Cohen barely left Mills’s side. He read the tran­scripts of the chairman’s speeches, quipped Cohen’s biographer, “the way that Sinologists studied statements from Mao. 59 On the surface, the two men seemed not at all compatible. Cohen, the son of Jewish immigrants, had at­tended the University of Wisconsin and its Experimental College. There he had read Lincoln Steffens and Henry Adams and flirted with socialism. “I come from a tradition of social reform in Wisconsin under the La Follettes and under professor John R. Commons, which brought me into the New Deal,” he later said of himself.” 60 Yet, both men had great respect for each other. “He is a man of great capacity and a man of great ability, and the most important part of that is that he has the respect of his colleagues in Congress,” Cohen said of Mills.61 De­spite their excellent working relationship, the two Wilburs were not able to put together a satisfactory Medicare compromise before the election. “Now they’ve [Republicans and the AMA] got us screwed on Medicare,” Johnson told House Majority Leader Carl Albert. “We’re screwed good.”62

Then came the election of 1964, with LBJ’s sweeping mandate and the addi­tions to the already large Democratic majority in the House. Public opinion polls were showing a two-to-one margin in favor of some type of national med­ical insurance for the aged. For many middle-class families, matters had reached the point where they had to choose between proper medical care for aged par­ents and college for their children. Johnson appealed to Mills. “If you can get something you can possibly live with and defend,” he told the chairman of Ways and Means, “that these people will not kick over the bucket with, it’ll mean more than all the bills we’ve passed put together and it’ll mean more to poster­ity and to you and to me.”63 The morning following the election, Mills in­formed reporters that he “would be receptive to a Medicare proposal in the upcoming session.”64 Desperate, the AMA backed a bill that it dubbed Elder-care. Persons over sixty-five could purchase Blue Cross/Blue Shield or com­mercial insurance by paying all or none of the cost depending on their income. The expense would be borne by the states and the federal government. Then on February 4, 1965, Republican John Byrnes introduced “Bettercare,” a plan that would cover hospital and doctor bills as well as selected patient services. The government would pay two-thirds of the cost from the general fund and the re­mainder would be defrayed by premium payments scaled to income. To Wilbur Cohen’s horror, Mills told Byrnes that he liked the idea behind Bettercare. 65 He then proposed what he called a “three-layer cake.” The bottom layer would be a plan to take comprehensive care of those without means. Medicare would be the middle layer, providing hospital care for those covered by Social Security. Topping off the confection would be Bettercare, a voluntary system to defray the cost of doctor bills. Cohen was stunned—and delighted. No sooner had Mills made his proposal than everyone in the committee room knew “that it was all over,” said one committee member. “The rest would be details. In thirty seconds, a $2 billion bill was launched, and the greatest departure in the social security laws in thirty years was brought about.” 66 The subsequent “debate” in the House lasted one day. When Mills stepped to the podium to present his plan, he received a standing ovation from both sides of the aisle. The House passed the three-layer cake by a vote of 313 to 115.

On the morning of March 26, after Mills’s committee had voted out the So­cial Security Amendments Act of 1965 (Medicare), LBJ summoned the congres­sional leadership of both houses to the White House for a discussion of the measure. Unbeknown to his guests, Johnson had arranged for television cover­age. Before the cameras LBJ praised Mills and his three-tiered plan and then turned to the venerable Harry Byrd, chairman of the Senate Finance Committee and an archenemy of Medicare. “Senator Byrd, would you care to make an ob­servation?” Startled, the conservative Virginian said he had not studied the mea­sure but was prepared to hold hearings on it. “And you have nothing that you know of that would prevent that coming about in reasonable time?” “No,” said Byrd quietly. “So when the House acts and it is referred to the Senate Finance Committee, you will arrange for prompt hearings.” “Yes,” Byrd replied, even more quietly.67 As he was leaving, the congressman observed wryly to reporters that if he had known he was going to be on television, he would have dressed more formally. Byrd was as good as his word. Hearings proceeded without a hitch, and on July 9 the Senate approved the amendments to the Social Security Act of 1965 creating Medicare and Medicaid by a vote of sixty-eight to twenty-one.68 “Biggest Change Since the New Deal,” trumpeted Newsweek’s headline.69 Johnson was ecstatic. “[This] gives your boys [in Congress] something to run on if you’ll just put out that propaganda,” he chortled to Larry O’Brien. “That they’ve done more than they did in Roosevelt’s Hundred Days.”70

There was one final hurdle to be cleared. Some people feared that the AMA might refuse to participate in Medicare and Medicaid. The Ohio Medical Asso­ciation, representing ten thousand physicians, had already adopted a resolution to boycott the new programs. When, subsequently, some twenty-five thousand doctors gathered in New York on June 20 for the annual AMA convention, the House of Delegates directed its officers to meet with the president to discuss implementation of the legislation. Shortly before the gathering was to take place, AFL-CIO president George Meany called to express his concern. John­son asked him, “George, have you ever fed chickens?” “No,” Meany answered. “Well,” the president said, “chickens are real dumb. They eat and eat and eat and never stop. Why they start shitting at the same time they’re eating, and before you know it, they’re knee-deep in their own shit. Well, the AMA’s the same. They’ve been eating and eating nonstop and now they’re knee-deep in their own shit and everybody knows it. They won’t be able to stop anything.”71

On June 29, the AMA leadership assembled in the West Wing and were promptly given a large dose of the Johnson treatment. LBJ began by saying what wonderful people doctors were, recalling how the local physician in Johnson City had made numerous house calls to treat his ailing father. He stood and stretched; they stood. He sat. They sat. LBJ then delivered a moving statement about “this great nation and its obligation to those who had helped make it great and who were now old and sick and helpless through no fault of their own.” He stood again. They stood. He sat, and they followed suit, now perfectly clear as to who was in control.72 Suddenly Johnson brought up Vietnam. Would the AMA help in arranging for physician volunteers to serve for short periods in that country to help the civilian population gain a modicum of health? “Your coun­try needs your help. Your President needs your help.” In unison, the AMA offi­cials said that they would be glad to participate. “Get the press in here,”Johnson shouted to a lieutenant. To the journalists, the president announced the AMA’s commitment to help in Vietnam and praised their patriotism. One of the re­porters asked if the AMA was going to boycott Medicare. Johnson piped up with mock indignity: “These men are going to get doctors to go to Vietnam where they might be killed. Medicare is the law of the land. Of course, they’ll support the law of the land. Tell him,” LBJ said, turning to the head of the dele­gation. That worthy nodded and said, “We are, after all, law-abiding citizens, and we have every intention of obeying the new law” A few weeks later, the AMA announced its intention to support Medicare.73

“The application of Medicare to twenty million people on July 1 was perhaps the biggest single governmental operation since D-Day in Europe during World War II,” Wilbur Cohen subsequently observed.74 By early May 1966, 16.8 mil­lion elderly, 88 percent of those eligible, had voluntarily enrolled for medical in­surance. By that date, over 90 percent of the nation’s accredited hospitals and more than 80 percent of nonaccredited facilities had applied for participation. Over the years, Medicare and Medicaid transformed the lives of millions of American families. The impoverished, elderly, and dependent no longer had to go without health care; middle-class families no longer had to choose between college for their children and proper medical care for their grandparents. But Wilbur Mills had been right to be worried. There were no effective controls on costs. Hospitals and physicians were entitled to be reimbursed for reasonable costs, which were whatever hospitals and physicians said they were. Total Medicare expenditures amounted to $3.5 billion in the first year of the program; by 1993 total costs had risen to $144 billion, and Americans were spending ap­proximately 15 percent of the gross national income on health care.75

As was true of many of the Great Society measures, Medicare was a civil rights as well as a health care bill. In those hospitals and doctors’ offices that par­ticipated, “colored” and “white” signs disappeared from waiting rooms, rest­rooms, and water fountains. Harry McPherson remembered that in the days following passage of the Act, the White House was deluged with letters and telegrams from outraged southerners. Noting that federal law required hospi­tals and clinics not to discriminate and to desegregate to receive federal funds, one correspondent told the president, “And they won’t Lyndon. You know that. Do you want to be responsible for closing the St. Francis Hospital in Biloxi, Mississippi? That’s what will happen if you put this thing into effect. . . Doc­tors won’t treat the coloreds, and the nurses won’t treat them.”76 It was a great gamble, McPherson recalled. “Whatever he decided,” he said of the president, “thousands of people, either the elderly or the blacks, might have been deprived of hospitalization. It was an excruciating decision to make, but he made it. Comply. And they did.”77


Johnson may well have been the hardest working President that the United States has ever had. His constant activity, and continual manipulation and cajoling of others as he bent and shaped the ways in which the country took care of its own and found its firm place in the world. Woods takes full advantage of all the documents and tapes and records that have opened in recent years, and uses them all in forming LBJ. For those of us who think we knew a lot about Johnson, there are new things to learn on the pages of LBJ. For those who have firm opinions about any one or other aspect of Johnson’s presidency, chances are there’s a larger perspective in LBJ for consideration. For optimists who want to enjoy what a Presidency can be, the pages of LBJ reinforce how much can change as a result of the actions of an American President.


Steve Hopkins, October 25, 2006




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