Today’s debate over comprehensive health care reform in the United States suffers from a lack of historical perspective. Many in the public seem to think that the crisis in our health care system recently appeared on the political scene. But in fact, the first calls for universal coverage came not under President Clinton in the 1990’s, or even President Johnson in the 1960’s, but during the Progressive Era – almost a century ago. In 1912, Teddy Roosevelt ran for president as the Progressive Party candidate on a platform that included national health insurance. Irving Fisher, a prominent Yale economist and reform leader, argued in 1917 that health insurance must be universal and obligatory – something he also thought was right around the corner.
Support for universal coverage ramped up during the years of the Great Depression and continued through World War II and the post-war years. Although health care costs are higher today than ever, concerns over rising costs also fueled mid-twentieth century calls for reform. In 1932, the Committee on the Costs of Medical Care released a report stating that millions of families who were not considered poor by conventional measures still faced financial ruin when family members got sick or hurt. But ironically, President Roosevelt, father of the New Deal and Social Security, never publicly advocated for universal coverage. Even President Truman, who delivered a number of special messages to Congress on the subject and is seen by some proponents of reform as the first great champion of universal coverage, did not aggressively take his cause to the American people.
Reform efforts achieved major success with the passage of Medicare in 1965. While President Johnson’s political skill played a key role in this achievement, so too did a unique political climate. In the wake of JFK’s assassination, Johnson received 61 percent of the popular vote and a two-thirds majority in Congress in the 1964 election, providing him a unique opportunity to pursue his legislative agenda. Momentum for reform built again with the election of President Clinton, but Clinton was never able to garner the level of support Johnson had. Ultimately, the public came to fear the Clinton plan’s complexity more than the status quo.
Organized opposition to reform has had a similarly long history. Jill Lepore of the New Yorker describes how insurance companies warned in the late 1910’s that providing universal health care in California would “spell social ruin to the United States.” By the 1960’s, the threat of “socialized medicine” was in full force. The New York Times reported in June 1965 that the American Medical Association (AMA) had placed ads in 100 newspapers calling Medicare “the beginning of socialism.” Ironically, the AMA is now an entrenched defender of Medicare, denouncing proposed cuts to Medicare payment rates and advocating for changes that will “ensure seniors can count on Medicare now and for years to come.”
The key historical difference is that health care reform today faces a significantly more complex lawmaking landscape than in the past. In 1975, congressional rules changed so that a single piece of legislation could be referred to multiple committees. In the 1960’s, Johnson could concentrate his efforts on one committee chairman (whose opposition or support was paramount, but ultimately obtainable). Today, a president supporting health reform might have to work with five or six committee chairs, all with differing agendas and priorities.
Political parties are also more divided than ever. Medicare passed with the support of 83 moderate Republicans; this level of bipartisan support would be truly extraordinary in Congress today. According to the Congressional Quarterly, 2009 was the most partisan year since they started measuring in 1953. Over 50 percent of votes in the House and 70 percent of votes in the Senate were partisan (majorities in both parties voted against each other).
Finally, trust in government matters, and it is currently at an all-time low. In a 1958 American National Election Study, 73 percent of respondents said they trusted the federal government “just about always” or “most of the time.” A New York Times/CBS News poll from 2008 showed that number to be just 17 percent. While past and current polls have shown that Americans by and large support some kind of health care reform, distrust in government has increasingly overwhelmed major reform efforts.
In light of the long history of reform efforts and today’s legislative complexities, the recent passage of a health care reform bill under President Obama represents a significant accomplishment. But the debate over universal coverage will not end here, and understanding the history of reform efforts will remain vital as the debate continues. The history of health care reform is long, and the reasons for success and failure are complex. Each decade of debate has been both a repeat of the past and a unique moment in time. Unless we fully understand this dynamic history, today’s debate can only be based on semi-truths at best. And surely an issue as important as this one deserves better.
‡ Sarah Cassanego is an alumna of the Sanford School of Public Policy at Duke University (Master of Public Policy program).