In response to:

Should Obama's Health Care Be Opposed?: An Exchange from the June 7, 2012 issue

To the Editors:

In Marcia Angell’s critique of Ronald Dworkin’s article about the Affordable Care Act’s mandate to buy health insurance, she advocates for replacing the ACA with a single-payer system [“Should Obama’s Health Care Be Opposed?,” NYR, June 7]. In his rebuttal to her letter, Dworkin states that “even Senator Edward Kennedy, who was among the most powerful advocates of a single-payer system, long ago abandoned all hope of achieving it.” That is not quite correct.

I was the first physician Senator Kennedy hired as an adviser on health care. I served on his staff between 1971 and 1976 and continued to advise him on matters of health policy until his death in 2009. Although Senator Kennedy was acutely (and painfully) aware of the political obstacles that stood in the way of passing legislation expanding Medicare to eventually cover the entire American population, he nonetheless continued to believe it would be the best policy. On April 25, 2007, and over the objections of some on his staff at the time, he (together with Congressman John Dingell) introduced a bill that would do just that.

To the end, Senator Kennedy believed in going for the best.

Philip Caper, MD
Brooklin, Maine

Jeff Madrick, whom Ronald Dworkin cited as a source, replies:

As Dr. Caper writes, Senator Kennedy always believed that a single-payer system was the best way to achieve adequate health care for all Americans. Not only did he sign onto the Dingell bill, he also reiterated his support of Medicare for all in his book, America Back on Track, which I helped write.

But in the political world, he had essentially backed off support for pure single-payer systems by the late 1970s. He realized the approach had too many powerful enemies. As Paul Starr points out in his book Remedy and Reaction, Kennedy proposed a plan for universal coverage in 1979 but that plan enabled Americans to buy insurance from Blue Cross, HMOs, or other private insurers. He wrote about his decision to compromise with the private health care industry in his last memoir.

Senator Kennedy was always a political pragmatist. Even in the early 1970s, he was willing to compromise on a full-fledged single-payer plan by requiring some payments by enrollees in opposition to the unions. And let us keep in mind that he supported President Obama’s less than perfect plan as well.

This does not mean Kennedy was not an idealist. His deep-felt idealism was his most admirable trait on issues across the political landscape. But he knew more about how to get legislation passed than almost any of his peers and certainly than anyone around today. It meant compromise, and it is why he accomplished so much. Many of us less-involved observers would not be good at that. But he was.