Struggles for National Health Reform in the United States
January 2003, Vol 93, No. 1
| American Journal of Public Health 86-91
Anne-Emanuelle Birn, ScD,
Theodore M. Brown, PhD, Elizabeth Fee, PhD and Walter J. Lear,
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.
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: firstname.lastname@example.org).
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
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
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
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
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
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
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
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.
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