A Brief History: Universal Health Care
Efforts in the US
This is long. It has to be, to cover all the bases. If you
really give a damn about health care and its history in US political debate, read this and
become more educated.
Much of what follows
is excerpted from talk given by Karen S. Palmer MPH, MS in 1999 and edited
sparingly (most of the time) by me. The timing of this was the end of Bill
Clinton’s presidency, and its (failed) attempts at health care reforms. The
sole reason I post this is to show that Americans of both political parties
have, over the last more than 100 years, discussed and advocated universal health care. Listening to the
lunatic right would give the impression to the uninformed that health care for
all Americans is a 21st century plot hatched by the current Democratic
administration. In fact, that is wrong by over a century! The only difference
between then and now is that the Congress and President actually did something
about it in the Affordable Care Act (A.C.A.) It must be noted (although few want to) that
Theodore Roosevelt, a Republican President was the first POTUS to actively
support such a move!
I will break up individual initiatives by organizations and/or
administrations, where possible, in an attempt to clarify what are actually in
several instances, parallel threads of the issue.
Late 1800’s
to Medicare
“The campaign for some form of universal government-funded
health care has stretched over a century
in the US. On occasion, advocates
believed they were on the verge of success; yet each time they faced defeat.
The evolution of these efforts and the reasons for their failure make for an
intriguing lesson in American history, ideology, and character.”
Other developed countries have
had some form of social insurance (that later evolved into national insurance)
for nearly as long as the US has been trying to get it.
Some
European countries started with compulsory sickness insurance, one of the first
systems, for workers beginning in Germany in 1883; other countries including
Austria, Hungary, Norway, Britain, Russia, and the Netherlands followed all the
way through 1912. Other European countries, including Sweden in 1891, Denmark
in 1892, France in 1910, and Switzerland in 1912, subsidized the mutual benefit
societies that workers formed among themselves. (It should be noted that this
actually constituted a cooperative relationship between labor and Government
regarding health care. As we shall see in a bit, that is the opposite of the
way unions related to health care initiatives in the US!) So for a very long time, other countries have
had some form of universal health care or at least the beginnings of it.
In a seeming paradox, the British and German systems were
developed by the more conservative governments in power, specifically as a
defense to counter expansion of the socialist and labor parties. They used
insurance against the cost of sickness as a way of “turning benevolence to
power”. While that may lead some to question the motives of the Conservative
governments responsible, there can be little doubt that it did undercut a
strong point for labor – that being the postulate put forth by labor
organizations that only strong trade unionism could provide the basic needs of
working class individuals.
US
circa 1883-1912, including Reformers and the Progressive Era:
What was the US doing
during this period of the late 1800’s to 1912? In the golden age of “laissez
faire” The government took no actions to subsidize voluntary funds or make sick
insurance compulsory; Essentially the federal government left matters to the
states and states left them to private and voluntary programs. It must be noted
here, that the US was simply about 50 years behind Europe, and was basking in
the myth, operative until at least WWI, that the great oceans separated [and
protected] us from not only physical threats, but ideological threats from
Europe as well. The US did have some voluntary funds that provided for their
members in the case of sickness or death, but there were no legislative or
public programs during the late 19th or early 20th century.
In the Progressive
Era, ushered in by the Republican party behind Roosevelt, and Taft, and extending
through Woodrow Wilson from 1901-1919, reformers were working to improve social
conditions for the working class. However unlike European countries, there was
not powerful working class support for broad social insurance in the US The
labor and socialist parties’ support for health insurance or sickness funds and
benefits programs was much more fragmented than in Europe. Therefore the first
proposals for health insurance in the US did not come into political debate
under anti-socialist sponsorship as they had in Europe.
Theodore Roosevelt 1901 — 1909
During the Progressive Era, President Theodore Roosevelt was
in power and although he supported health insurance because he believed that “No
country could be strong whose people are sick and poor” (ed. Note: What a concept!), most of
the initiative for reform took place outside of government. Roosevelt’s
successors were mostly conservative leaders, who postponed for about twenty
years the kind of presidential leadership that might have involved the national
government more extensively in the management of social welfare.
AALL
Bill 1915
In 1906, the American Association of Labor Legislation
(AALL) finally led the campaign for health insurance. They were a typical
progressive group whose mandate was not to abolish capitalism but rather to
reform it. Their proposal limited
coverage to the working class and all others that earned less than $1200 a
year, including dependents. The services of physicians, nurses, and hospitals
were included, as was sick pay, maternity benefits, and a death benefit of
fifty dollars to pay for funeral expenses. This death benefit becomes significant
later on. Costs were to be shared between workers, employers, and the state. It must
be noted that an annual income of $1200
in 1900 equates to one of about $32,600 in 2012, which actually made this a
fairly broad program proposal!
AMA supported AALL Proposal
In 1914, reformers sought to involve physicians in
formulating this bill and the American Medical Association (AMA) actually
supported the AALL proposal. They found prominent physicians who were
not only sympathetic, but who also wanted to support and actively help in
securing legislation. In fact, some physicians who were leaders in the AMA
wrote to the AALL secretary: “Your plans are so entirely in line with our own
that we want to be of every possible assistance.” By 1916, the AMA board
approved a committee to work with AALL, and at this point the AMA and AALL
formed a united front on behalf of health insurance (times have definitely
changed)!
In 1917, the AMA House of Delegates favored compulsory
health insurance as proposed by the AALL, but many state medical societies
opposed it. There was disagreement on the method of paying physicians and it
was not long before the AMA leadership denied it had ever favored the measure.
The real story here is probably doctors at local levels concerned about their
income rather than the health of the population.
AFL opposed AALL Proposal
In what seems to be a
counterintuitive move, the president of the American Federation of Labor
repeatedly denounced compulsory health insurance as an unnecessary
paternalistic reform that would create a system of state supervision over
people’s health. They apparently worried that a government-based insurance system
would weaken unions (the real reason) by usurping their role in
providing social benefits. Their central concern was maintaining union
strength, which was understandable in a period before collective bargaining was
legally sanctioned.
Private
insurance industry opposed AALL Proposal
The commercial
insurance industry also opposed the reformers’ efforts in the early 20th
century. There was great fear among the working class of what they called a
“pauper’s burial,” so the backbone of insurance business was policies for
working class families that paid death benefits and covered funeral expenses.
But because the reformer health insurance plans also covered funeral expenses,
there was a big conflict. Reformers felt that by covering death benefits, they
could finance much of the health insurance costs from the money wasted by
commercial insurance policies who had to have an army of insurance agents to
market and collect on these policies. But since this would have pulled the rug
out from under the multi-million dollar commercial life insurance industry,
they opposed the national health insurance proposal. In this respect, things
remain much as they were, with literally billions of dollars pumped into anti-Affordable
Care Act and its provisions lobbying efforts. Not one scintilla of real concern
for the insured is apparent in these efforts rather they are, as are most
lobbying efforts, in support of the
payer’s bottom line and screw the public interest! (As a personal addendum to this paragraph, it is noteworthy that of the
top 15 special interest groups in the US, thirteen give the clear majority of
their contributions to GOP candidates or legislative causes. The Retired
community as a group, donate heavily to GOP causes, with Speaker John Boehner
being their top recipient. Boehner is also the top individual recipient of the
Insurance, Electric utilities, Lobbyists overall, and a category called “Misc. Mfg
and Distributing.” Of those industries related to the Affordable Care Act and
on record as opposing it, all heavily support and send most of their lobbying
dollars to Republicans. Interestingly enough, so does the banking industry. The
retired community, curiously enough, represents those Americans already covered
by a Government mandated health care program (Medicare) and by all polls, more
than satisfied with it. This makes the objections of the retired community to
the A.C. A. even more self serving and venal.) All these donations, however,
pale in comparison to that of the Koch Brothers, who individually and through “Americans
for Prosperity” donated over $60 million to the 2012 campaigns, over 95% of
that to GOP candidates.
WWI and anti-German fever
In 1917, the US
entered WWI and anti-German fever rose. The government-commissioned articles
denouncing “German socialist insurance” and opponents of health insurance
assailed it as a “Prussian menace” inconsistent with American values. Other
efforts during this time in California, namely the California Social Insurance
Commission, recommended health insurance, proposed enabling legislation in
1917, and then held a referendum. New York, Ohio, Pennsylvania, and Illinois
also had some efforts aimed at health insurance. But in the Red Scare, immediately
after the war, when the government attempted to root out the last vestiges of
radicalism, opponents of compulsory health insurance associated it with
Bolshevism and buried it in an avalanche of anti-Communist rhetoric. This
marked the end of the compulsory national health debate until the 1930’s.
Why did the Progressives fail?
Opposition from
doctors, labor, insurance companies, and business contributed to the failure of
Progressives to achieve compulsory national health insurance. In addition, the
inclusion of the funeral benefit was a tactical error since it threatened
the gigantic structure of the commercial life insurance industry.
Political naiveté on the part of the reformers in failing to deal with the
interest group opposition, ideology, historical experience, and the overall
political context all played a key role in shaping how these groups identified
and expressed their interests.
The
1930’s
In the 1930’s, the
focus shifted from stabilizing income to financing and expanding access to
medical care. By now, medical costs for workers were regarded as a more serious
problem than wage loss from sickness. For a number of reasons, health care
costs also began to rise during the 1920’s, mostly because the middle class
began to use hospital services and hospital costs started to increase. Medical,
and especially hospital, care was now a bigger item in family budgets than wage
losses.
The CCMC
Concerns over the
cost and distribution of medical care led to the formation of the Committee on
the Cost of Medical Care (CCMC) a self-created, privately funded group. The
committee was funded by 8 philanthropic organizations including the
Rockefeller, Millbank, and Rosenwald foundations. They first met in 1926 and
ceased meeting in 1932. The CCMC was comprised of fifty economists, physicians,
public health specialists, and major interest groups. Their research determined
that there was a need for more medical care for everyone, and they published
these findings in 26 research volumes and 15 smaller reports over a 5-year
period. The CCMC recommended that more national resources go to medical care
and saw voluntary, not compulsory, health insurance as a means to covering
these costs. Some CCMC members opposed
compulsory health insurance, but there was no consensus on this point within
the committee. The AMA treated their report as a radical document advocating
socialized medicine, and the conservative editor of JAMA called it “an
incitement to revolution.”
FDR’s first attempt
Next came Franklin D. Roosevelt (FDR), whose tenure
(1933-1945) was to be characterized by WWI, the Great Depression, and the New
Deal, including the Social Security Bill. One might have thought the Great
Depression would create the perfect conditions for passing compulsory health
insurance in the US, but with millions out of work, but unemployment insurance
took priority followed by old age benefits. FDR’s Committee on Economic
Security, the CES, feared that inclusion of health insurance in its bill, which
was opposed by the AMA, would threaten the passage of the entire Social
Security legislation. It was therefore excluded, scuttled once more by a group
whose oath starts “first, do no harm…….” Ironic, isn’t it?.
FDR’s second attempt - National Health Act
of 1939
There was one more push for national health insurance during
FDR’s administration: The Wagner National Health Act of 1939. Though it never
received FDR’s full support, the proposal grew out of his Tactical Committee on
Medical Care, established in 1937. The essential elements of the technical
committee’s reports were incorporated into Senator Wagner’s bill, the National
Health Act of 1939, which gave general support for a national health program to
be funded by federal grants to states and administered by states and
localities. However, the 1938 election brought a conservative resurgence and
any further innovations in social policy were extremely difficult.
Henry
Sigerist
Henry Sigerist, a very influential medical historian at Johns
Hopkins University, played a major role
in medical politics during the 1930’s and 1940’s. He passionately believed in a
national health program and compulsory health insurance. Several of Sigerist’s
most devoted students went on to become key figures in the fields of public
health, community and preventative medicine, and health care organization. Many
of them, including Milton Romer and Milton Terris, were instrumental in forming
the medical care section of the American Public Health Association, which then
served as a national meeting ground for those committed to health care reform.
1943 and onward through the decade
The Wagner Bill
evolved and shifted from a proposal for federal grants-in- aid to a proposal
for national health insurance. First introduced in 1943, it became the Wagner-Murray-Dingell
Bill. The bill called for compulsory national health insurance and a payroll
tax. In 1944, the Committee for the Nation’s Health, (which grew out of the
earlier Social Security Charter Committee), was a group of representatives of
organized labor, progressive farmers, and liberal physicians who were the
foremost lobbying group for the Wagner-Murray-Dingell Bill. Prominent members
of the committee included Senators Murray and Dingell, the head of the
Physician’s Forum, and Henry Sigerist. Opposition to this bill was enormous and
the antagonists launched a scathing red baiting attack on the committee saying
that one of its key policy analysts, I.S. Falk, was a conduit between the
International Labor Organization (ILO) in Switzerland and the United States
government. The ILO was red-baited as “an awesome political machine bent on
world domination.” They even went so far was to suggest that the United States
Social Security board functioned as an ILO subsidiary. Although the
Wagner-Murray-Dingell Bill generated extensive national debates, with the
intensified opposition, the bill never passed by Congress despite
its reintroduction every session for 14 years! Had it passed, the Act
would have established compulsory national health insurance funded by payroll
taxes.
Truman’s Support
After FDR died,
Truman became president, his tenure is
characterized by the Cold War and Communism. The health care issue finally
moved into the center arena of national politics and received the unreserved
support of an American president. Though he served during some of the most
virulent anti-Communist attacks and the early years of the Cold War, Truman
fully supported national health insurance. But the opposition had acquired new
strength. Compulsory health insurance became entangled in the Cold War and its opponents
were able to make “socialized medicine” a symbolic issue in the growing crusade
against Communist influence in America.
Truman’s plan for national health insurance in 1945 was
different than FDR’s plan in 1938 because Truman was strongly committed to a
single universal comprehensive health insurance plan. Whereas FDR’s 1938
program had a separate proposal for medical care of the needy, it was Truman
who proposed a single egalitarian system that included all classes of society,
not just the working class. Senior Republican Senator Taft promptly declared,
“I consider it socialism. It is to my mind the most socialistic measure this
Congress has ever had before it.” Taft suggested that compulsory health
insurance, like the Full Unemployment Act, came “right out of the Soviet
constitution” and walked out of the hearings. The AMA, the American Hospital
Association, the American Bar Association, and most of the nation’s press had
no mixed feelings; they hated the plan. The AMA claimed it would make doctors “slaves”,
even though Truman emphasized that doctors would be able to choose their method
of payment.
In 1946, the
Republicans gained control of Congress and had no interest in enacting national
health insurance. They charged that it was part of a large socialist scheme.
Truman responded by focusing even more attention on a national health bill in
the 1948 election. After Truman’s surprise victory in 1948, the AMA thought
Armageddon had come. They assessed their members an extra $25 each to
resist national health insurance, and in 1945 they spent $1.5 million on
lobbying efforts which at the time was the most expensive lobbying effort in
American history. They had one pamphlet that said, “Would socialized
medicine lead to socialization of other phases of life?
The AMA and its supporters were again very successful in
linking socialism with national health insurance, and as anti-Communist
sentiment rose in the late 1940’s and the Korean War began, national health
insurance became vanishingly improbable. Truman’s plan died in a congressional
committee. Instead of a single health insurance system for the entire
population, America would have a system of private insurance for those who
could afford it and public welfare services for the poor. Discouraged by yet
another defeat, the advocates of health insurance now turned toward a more
modest proposal they hoped the country would adopt: hospital insurance for the
aged and the beginnings of Medicare. After
WWII, other private insurance systems expanded and provided enough protection
for groups that held influence in American to prevent any great agitation for
national health insurance in the 1950’s and early 1960’s. Union-negotiated
health care benefits also served to cushion workers from the impact of health
care costs and undermined the movement for a government program.
Why did these efforts
for universal national health insurance fail again?
For many of the same
reasons they failed before: interest group influence (code words for class),
ideological differences, anti-communism, anti-socialism, fragmentation of
public policy, the entrepreneurial character of American medicine, a tradition
of American voluntarism, removing the middle class from the
coalition of advocates for change through the alternative of Blue Cross private
insurance plans, and the association of public programs with charity,
dependence, personal failure and the almshouses of years gone by.
Johnson and Medicare/caid
Rhode Island
congressman Aime Forand introduced a new proposal in 1958 to cover hospital
costs for the aged on social security. Predictably, the AMA undertook a massive
campaign to portray a government insurance plan as “A threat to the patient-doctor
relationship.” But by concentrating on the aged, the terms of the
debate began to change for the first time. There was major grass roots support
from seniors and the pressures assumed the proportions of a crusade. In the
entire history of the national health insurance campaign, this was the first
time that a ground swell of grass roots support forced an issue onto the
national agenda. In response, the
government expanded its proposed legislation to cover physician services, and
what came of it were Medicare and Medicaid. The necessary political compromises
and private concessions to the doctors (reimbursements of their customary,
reasonable, and prevailing fees), to the hospitals (cost plus reimbursement),
and to the Republicans created a 3-part plan, including the Democratic proposal
for comprehensive health insurance (“Part A”), the revised Republican program
of government subsidized voluntary physician insurance (“Part B”), and
Medicaid. Finally, in 1965, Johnson signed it into law as part of his Great Society
Legislation, capping 20 years of congressional debate.
Conclusion: What does history teach us? 6
suggestions
1. Henry Sigerist reflected in his own diary in 1943 that he
“wanted to use history to solve the problems of modern medicine.” Damning her
own naivete, Hillary Clinton acknowledged in 1994 that “I did not appreciate
how sophisticated the opposition would be in conveying messages that were "effectively
political even though substantively wrong.” She should have read the
history first!
2. The institutional representatives of society
do not always represent those that they claim to represent, just as the
AMA does not represent all doctors. This lack of representation presents an
opportunity for attracting more people to the cause. The AMA has always played
an oppositional role and it would be prudent to build an alternative to the AMA
for the 60% of physicians who are not members.
3. Whether we like it
or not, we have to have to deal with the persistence of the narrow vision of
middle class politics. It is arguable that the majority opinion of national
health insurance has everything to do with repression and coercion by the
capitalist corporate dominant class and that
conflict and struggles that continuously take place around the issue of health
care unfold within the parameters of class and that coercion and repression are
forces that determine policy. When we talk about interest groups in this
country, it is frequently a code for class.
5. Grass roots initiatives contributed in part to the
passage of Medicare. . Ted Marmor offers these lessons from the past:
“Compulsory health insurance, whatever the details, is an ideological
controversial matter that involves enormous financial and professional stakes.
Such legislation does not emerge quietly or with broad partisan support.
Legislative success requires active presidential leadership, the commitment of
an Administration’s political capital, and the exercise of all manner of persuasion
and arm-twisting.”
6. One Canadian
lesson — the movement toward universal health care in Canada started in 1916 and took until 1962 for passage of both
hospital and doctor care in a single province. It took another decade for the
rest of the country to catch on. That is about 50 years all together. It wasn’t
like they sat down over afternoon tea and crumpets and said “Please pass the
health care bill so we can sign it and get on with our day.” They fought, they threatened, doctors went on
strike, refused patients, people held rallies and signed petitions for and
against it, burned effigies of government leaders, hissed, jeered, and booed at
the doctors or the Prime Minister depending on whose side they were on. (sound
familiar, like the Tea Party, for example?) In a nutshell, they weren’t the
sterotypical mild mannered polite Canadians. Although there was plenty of
resistance then, now you could far more
easily take away Christmas In Canada than health care, despite the rhetoric that
you may hear to the contrary.
