Editor’s Note: During his 47 years in the Senate, the late Senator Edward Kennedy of Massachusetts was a lion of U.S. health care and health policy. We at Health Affairs, along with much of the rest of America, grieve at his passing.  We recently asked Democratic and Republican politicians, policy experts, and former Senate staff to write for us about the senator’s many contributions.  We now publish several of these on the Health Affairs Blog, including the piece  by Theodore Marmor below, and will also issue Web Exclusive versions for the archives in the weeks to come.

 – Susan Dentzer, Editor-in-Chief

Senator Edward Kennedy’s passing, a central question for me as a scholar is simple to state, but complicated to answer. Would American medical care — its practices and its policies — be very different had the senator taken up a business career like his father rather than a political career like his brothers

In one respect the answer seems straightforward. Neither Senator Kennedy nor anyone else has pulled off the major “overhaul” that has been a constant topic of political discussion since at least the early 1960s. We are in 2009 debating about almost exactly the same topics that Senator Kennedy addressed in his 1972 book, In Critical Condition. The costs then were skyrocketing, to use a phrase common to 2009. The financial barriers to care were one major object of the 1972 book’s reform agenda, with attention to areas of poor quality, inadequate supply of services, and vastly complicated insurance packages that left too many in fear of bankruptcy from being sick or injured. It is no surprise that when former Senator Tom Daschle set out to write his reform plan for a Democratic president who might emerge in 2009, he used the title Critical. It is noteworthy that none of the commentary on the 2008 Daschle book that I came across in writing a review of it mentioned the Kennedy forerunner, itself a sign of how hard it is to maintain an accurate historical perspective on a reform process that has now stretched over at least the decades since Medicare and Medicaid were enacted in 1965.

It would be a mistake, however, to treat wholesale health reform as the standard for evaluation. American political institutions are designed constitutionally to make large-scale reform in any sphere difficult. And, if no one — from presidents on down — has been able to meet that test, there are still other appropriate benchmarks by which to judge the role of a health policy leader. One is that leader’s role in setting the agenda and framing the debate over the reform of American medical care. Another is whether a leader like Senator Kennedy made a smaller but significant difference in policy and whether, in slightly different circumstances, he might have made a major difference.

Role In Setting The Agenda

By the first standard, Senator Kennedy was a noteworthy figure. He brought passion, eloquence, and clarity to the debate about what American medical care should be like. In the 1970s, he not only jousted with President Nixon about what form national health insurance should take in America, but also clarified how medical care should be understood. Senator Kennedy construed medical care as what academics would regard as a merit good, rather than a market good. That is, he unapologetically and powerfully defended the argument that access to medical care should be a function of medical need and the ability to benefit from treatment. He rejected — first in the early 1970s and regularly thereafter — the view that care (or health insurance) should be allocated by the market test of willingness and ability to pay. It is easy to forget how few American political leaders have framed health reform in his terms.

This past summer I watched on television a retrospective documentary that reminded me of Kennedy’s eloquence and passion in this sphere. I was particularly moved by how he compared his own treatment for a broken back, caused by an airplane crash, with the fate of other injured Americans lacking access to his money or his health coverage. It was no surprise when, in the 1970s, Senator Kennedy expressed enthusiasm for the system of national health insurance Canadians had managed to stitch together after rejecting America’s course.

Making A Difference

By the second criterion — having discernible influence amid less dramatic change — Kennedy, if anything, cut even more prominent a figure. He combined a vivid, uncompromising conception of what reforms were needed with an ability to find common ground with adversaries on less contentious policy changes. An example was Kennedy’s helpful role in creating the Children’s Health Insurance Program (CHIP), which to many appeared to be an achievable victory at a time when more sweeping reforms seemed impossible. There is more controversy over the role of Senate Democrats  who on pragmatic grounds accepted the 2003 Medicare Modernization Act as a reasonable compromise. Whatever the final verdict will be on that law, it’s clear that Senator Kennedy was able to combine pragmatic compromise with clarity about longer-term aspirations — a quality much missed in 2009.

Pragmatic compromise always raises an important evaluative and counterfactual question: whether the step by step expansion of coverage — as with CHIP — has advanced the United States along the road to universal coverage or provided a permanent detour away from it. The same question could be asked of Medicare, which seemed an incremental measure in 1965.

What role did the existence of Medicare play in the 1970s, when Senator Kennedy pressed for national health insurance through means other than expanding the already existing Medicare program? These are areas of disagreement among scholars, politicians, and pundits, and in that sense they remain a continuing part of the evaluation that the senator’s career will prompt.

Still another consideration is what difference Senator Kennedy might have made in somewhat different political circumstances. Imagine that the Senator had become a member of the Senate Finance Committee rather than his Health and Education (and later, Health, Education, Labor, and Pensions) Committee. Just the thought stimulates one to imagine a different proposal from what Senators Baucus and Grassley are imagining today, let alone what might have transpired over the past twenty years. And what if he had prevailed in his runs for the presidency in 1976 and 1980, rather than losing out to Jimmy Carter, a social policy conservative?

Missing From The Current Debate

It does not seem quite right to close a political scientist’s reflections with the indeterminacy of counterfactual speculations. Instead, the issue that seems most consequential now is what difference an active Senator Kennedy might have made in 2009. Most prominently, the Senate would have had a figure revered by many within the institution as the predictable struggles of principle and interest led to sharp debate. My sense is that a healthy Senator Kennedy would have made a difference over the past months — not in heading off the worst we have seen in terms of the low level of the current debate, but in reducing its prominence. And by that I mean his combination of eloquence and authority in health policy would have helped to focus the nation on the opportunity to make a real difference that 2009 seemed to provide.