Struggles for National Health Reform in the United States

January 2003, Vol 93, No. 1 | American Journal of Public Health 86-91
© 2003

Anne-Emanuelle Birn, ScD, Theodore M. Brown, PhD, Elizabeth Fee, PhD and Walter J. Lear, MD

Anne-Emanuelle Birn is with the Robert J. Milano Graduate School of Management and Urban Policy, New School University, New York, NY. Theodore M. Brown is with the Departments of History and of Community and Preventive Medicine, University of Rochester, NY. Elizabeth Fee is with the History of Medicine Division, National Library of Medicine, National Institutes of Health, Bethesda, Md. Walter J. Lear is with the Institute of Social Medicine and Community Health, Philadelphia, Pa.

Correspondence: Requests for reprints should be sent to Anne-Emanuelle Birn, ScD, Robert J. Milano Graduate School, New School University, 72 5th Ave, Room 503, New York, NY 10011 (e-mail: aebirn@newschool.edu).

Highlights in a century of popular efforts to achieve a national system of health care in the United States.

SOME KEY MOMENTS STAND out in a century of popular efforts to achieve a national system of health care in the United States. These efforts began with the Socialist Party’s endorsement of accident, unemployment, sickness, and old age insurance at its founding convention in 1901, an endorsement that was included in the Socialist Party presidential platform in 1904, 1908, and 1912.

Around the same time, a number of leading social reformers turned to the Progressive Party—and to its presidential candidate, Theodore Roosevelt—as a vehicle for moving the United States toward the hoped-for social justice long ignored by conventional politicians. They approached the party’s Chicago convention, held in August 1912, more as a fervent rallying of crusaders than as the standard and ritualized meeting of a political party. They crafted a party platform that expressed "the conscience of the people . . . born of the Nation’s awakened sense of justice."

The platform called for federal regulation of interstate corporations, the conservation of natural resources, graduated inheritance taxes, and women’s suffrage. It also called for industrial health and safety standards, the prohibition of child labor, a minimum wage for women, compensation for industrial accidents, injuries, and occupational diseases, and "the protection of home life against the hazards of sickness, irregular employment and old age through the adoption of a system of social insurance."

Jane Addams, founder of Hull House in Chicago, was the best-known social reform leader in the United States at this time. Dressed in white, she seconded Roosevelt’s nomination at the Progressive Party Convention while reformers in the audience waved red bandannas and cheered wildly (image opposite page). After the convention, Addams worked hard for the party, covering thousands of miles and giving hundreds of speeches. Progressive Party rallies packed 10 000 people into the Providence, RI, train station and drew 200 000 in Los Angeles, where they closed businesses and halted traffic. Addams and the other reformers were not discouraged when Roosevelt lost to Woodrow Wilson, for they saw the campaign as an educational opportunity and as the chance to build more permanent grassroots organizations for reform, such as the National Progressive Service, in which Addams headed a Department of Social and Industrial Justice.

Stimulated by this reform milieu, the American Association for Labor Legislation was organized in 1906 by a mixed group of academic economists and sociologists, liberal businessmen, and some labor leaders. After a campaign for the state-by-state adoption of workmen’s compensation laws, in 1915 it turned its attention to sickness insurance, "the next great step in social legislation." They published a draft bill, won the support of the American Medical Association (AMA), and promoted compulsory health insurance campaigns in 8 states. But by 1917, following the Russian Revolution and the United States’ entry into World War I, the national climate began to turn against reform. The AMA reversed its previous position in favor of compulsory health insurance and most states lost interest.⁶ In California, a referendum on the measure in 1918 led to a defeat by 358 324 votes to 133 856. In New York, support lasted longest, sustained by rank-and-file labor groups, trade unionists, women reformers, and socialists. Even in New York, however, the legislative measure, having passed the state senate on April 10, 1919, died in committee in the state assembly.

After these resounding defeats, popular support for compulsory health insurance did not resurface again until the 1930s, in the midst of the Great Depression. While President Franklin D. Roosevelt moved cautiously forward with his New Deal proposals, Congressman Ernest Lundeen of Minnesota introduced HR 2827, a bill for unemployment and social insurance, including wage replacement in case of illness. Backed by Minnesota’s Farmer-Labor Party, organizations of the unemployed, over 2000 locals of the American Federation of Labor, and the Communist and Socialist parties, Lundeen’s bill was approved by the House Committee on Labor. The National Joint Action Committee, in support of the Lundeen bill, engaged in an extensive campaign that included a 1935 convention attended by 3000 delegates. Four hundred of these delegates were women. The pamphlet What Every Working Woman Wants called for a variety of women’s health measures, including free birth control and 16 weeks of paid maternity leave (image at right). This campaign helped to push the Roosevelt administration to back social security legislation, albeit in a more limited form. Because of the opposition of organized medicine and its allies, health insurance was deliberately excluded from the president’s proposal.

National health insurance became an increasingly insistent public concern over the next decade. Organized labor demonstrated growing support for national health legislation; the US Congress held hearings around the various pro-insurance Wagner–Murray–Dingell bills of the 1940s (sponsored, respectively, by senators from New York and Montana and a congressional representative from Michigan), and President Truman officially endorsed national health insurance in 1948. But postwar politics dominated by Cold War ideology and the McCarthyite witch hunts fueled a massive antireform mobilization that undercut progressive health reform efforts. The AMA’s war chest also helped to defeat over 80% of pro–health insurance legislators in 1950.

With no viable political alternative, private sector health insurance coverage grew steadily, emphasizing workplace-based coverage negotiated under collective-bargaining agreements. By the early 1960s, three quarters of Americans would have some form of health insurance, although only 27% of their medical bills were covered.¹³ Because health insurance was so closely tied to full-time employment, retirees, the self-employed, the unemployed, and the underemployed were largely left out.

Beginning in the late 1950s, popular pressure refocused on the health needs of the elderly.¹⁴ Reform advocates created a "Medicare" strategy, tied to a campaign for a national program of hospital insurance for those older than 65. Organized labor strongly supported the legislative formulation of this program—the Forand bill, introduced by Representative Aime Forand, Democrat of Rhode Island—as did a variety of public health, social welfare, and reform groups and, increasingly, senior citizens’ councils. John F. Kennedy endorsed the Medicare proposal in his 1960 presidential campaign, and his administration supported a new bill, the King–Anderson bill, soon after his election. Resistance to the King–Anderson bill came from providers, the insurance sector, other business interests, conservative national political organizations, and certain members of Congress, including, notably, Representative Wilbur Mills, Democrat of Arkansas, the powerful chair of the House Ways and Means Committee.

The Kennedy administration encouraged a growing popular campaign organized by the senior citizens movement and labor organizations to dislodge the King–Anderson bill from committee, as when President Kennedy addressed a rally in a packed Madison Square Garden on May 20, 1962 (image at left). Kennedy’s forceful speech was carried on public service time by all 3 major television networks. Hours later, the AMA rented the arena, now empty except for the clutter left from the Kennedy rally, and (without showing the vacant hall) filmed AMA President Edward R. Annis, MD, making a rebuttal.

Medicare and related Medicaid legislation for the indigent passed in March 1965, in the wake of Kennedy’s assassination in November 1963, Lyndon Johnson’s landslide victory in November 1964, and the growing power of the civil rights movement and labor mobilization. Soon after the passage of Medicare, Walter Reuther, president of the United Automobile, Aerospace and Agricultural Implement Workers of America, called for universal health insurance in a speech delivered at the American Public Health Association. Reuther then helped organize a Committee for National Health Insurance and, in January 1969, Senator Edward Kennedy announced that he would introduce relevant legislation. Within a short time, a number of alternative and competing bills proliferated. Through the 1970s, several of these measures generated popular support from a variety of grassroots organizations, including the Gray Panthers and disability rights groups (image above left). President Nixon, the American Hospital Association, the insurance industry, and the AMA sponsored their own competing legislative proposals. Congressman Ronald Dellums (image above right), Democrat from California, introduced what was in many ways the most far-reaching measure in a bill calling for a national health service, an idea originally promoted by the Medical Committee for Human Rights, the medical arm of the civil rights movement. A range of women’s, civil rights, and labor organizations supported the Dellums bill, which proposed a national health system that would be financed through taxation, administered by local and state agencies, and jointly controlled by the consumers and providers of care.

Because of a marked conservative shift in national and congressional politics, the inflation accompanying the oil shocks of the 1970s, and economic anxieties caused by dramatic increases in health care costs, none of these programs succeeded and support for national health reform withered. The Carter administration was reluctant to endorse any national health insurance measure, and then the Reagan administration arrived in Washington with an agenda that included reducing federal regulatory intervention and cutting social programs. The Medicaid program experienced major cuts, and Medicare survived in large part because of the powerful political mobilization of senior citizens.

Thus, for most of the 1980s there existed little possibility of rekindling a campaign for national health insurance. Then the Reverend Jesse Jackson helped to organize the Rainbow Coalition and made a strong showing in the 1988 Democratic primary campaign (image). Especially after his surprising and impressive victory in the Michigan primary, others in the Democratic Party took his candidacy seriously. Jackson built a strong populist health reform message into his campaign and attracted considerable labor and grassroots support. While campaigning in Hartford, Conn, for example, Jackson said to a large and enthusiastic crowd, "There is something wrong with this nation when, here in this state, the insurance capital of the world, there are 300 000 people without health insurance."

Strong grassroots support for national health reform during the Jackson campaign has been credited with revitalizing the issue and getting it back onto the Democratic Party agenda. Presidential candidate Michael Dukakis’s platform in 1988 included a health reform plank, and in 1991 Harris Wofford won a come-from-behind race for a US Senate seat from Pennsylvania by focusing on the need for national health insurance. These developments led to Bill Clinton’s commitment to health reform in his presidential campaign and to his efforts at national health reform in 1993 and 1994. The failure of these efforts seemed to have closed another chapter in the century-long campaign for a national health care system.

But the 1990s also saw the birth of an impressive, popular, and truly grassroots movement for comprehensive, universal health coverage. One source was the Health Care for All movement, which began in 1991 and involved coalitions of local organizations and individuals in many cities and several states that were committed to national health reform, specifically to a taxpayer-funded national health insurance program. Together with the already-existing Physicians for a National Health Program, these groups engaged in small and large political activities, including mass demonstrations, lobbying members of Congress and other elected officials, educational forums, street theater, and campaigns for state and local referenda (image). These latter campaigns have been active in more than a dozen states, with those in Maryland, Oregon, and, most recently, Maine being particularly successful.

It may well be that the 21st century will finally see the successful completion of a task first begun at the start of the 20th.

 References
1. Quint HH. The Forging of American Socialism: Origins of the Modern Movement. Indianapolis, Ind: Bobbs-Merrill Co; 1953.

2. Elshtain JB. Jane Addams and the Dream of American Democracy: A Life. New York, NY: Basic Books; 2002: 189–194.

3. A contract with the people: platform of the Progressive Party adopted at its first national convention, Chicago, August 7, 1912.

4. Davis AF. The social workers and the Progressive Party: 1912–1916. Am Historical Rev. 1964;69:671–688.

5. Miller N. Theodore Roosevelt: A Life. New York, NY: William Morrow; 1992: 526–531.

6. Numbers R. Almost Persuaded: American Physicians and Compulsory Health Insurance, 1912–1920. Baltimore, Md: Johns Hopkins University Press; 1978.

7. Hoffman B. The Wages of Sickness: The Politics of Health Insurance in Progressive America. Chapel Hill: University of North Carolina Press; 2001:24–32.

8. Doenecke JD. Ernest Lundeen. In: Garraty JA, Carnes MC, eds. American National Biography. Vol 14. New York, NY: Oxford University Press; 1999: 135–136.

9. Brown E. The Social Insurance Congress. A F of L Rank and File Federationist. February 1935;2:6, 7, 15.

10. Garceau O. The Political Life of the American Medical Association. Cambridge, Mass: Harvard University Press; 1941.

11. Burrow JG. AMA: Voice of American Medicine. Baltimore, Md: Johns Hopkins Press; 1963.

12. Hirshfield DS. The Lost Reform: The Campaign for Compulsory Health Insurance in the United States from 1932 to 1943. Cambridge, Mass: Harvard University Press; 1970:42–70.

13. Numbers R. The Third Party: health insurance in America. In: Leavitt JW, Numbers R, eds. Sickness and Health in America: Readings in the History of Medicine and Public Health. 3rd ed, rev. Madison: University of Wisconsin Press; 1997:277.

14. Marmor TR. The Politics of Medicare. 2nd ed. New York, NY: A. de Gruyter; 2000.

15. Campion FD. The AMA and US Health Policy Since 1940. Chicago, Ill: Chicago Review Press; 1984:251.

16. Reuther W. The health care crisis: where do we go from here? Am J Public Health.1969;59:12–19.

17. Davis K. National Health Insurance: Benefits, Costs, and Consequences. Washington, DC: Brookings Institute; 1975.

18. Taking Jesse seriously. Time. April 11, 1988:12–19.

19. Navarro V. The rediscovery of the national health program by the Democratic Party of the United States: a chronicle of the Jesse Jackson 1988 campaign. Int J Health Serv.1989;19:1–18.

20. Skocpol T. Boomerang: Clinton’s Health Reform and the Turn Against Government. New York, NY: W. W. Norton; 1997.

21. Heclo H. The Clinton health plan: historical perspective. Health Aff.1995; 14:86–98.