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Below is a history abridged from Highjacked:The Road to Single Payer in the Aftermath of Stolen Health Care Reform, John Guyman, MD: Common Courage Press, Monroe, Maine, 2010, ISBN: 978-1-56751-402-5 Chap. 11: 219-226
 
And following that is a fascinating article  about an English Quaker, John Bellers, who proposed universal health care to Parliament in 1714. To read it, scroll down or click here.
 
And you can help write its future history by supporting BCHCEC.

HEALTHCARE REFORM
THE FIRST 100 YEARS

 
First Attempt: 1912-1917

In 1912, President Theodore Roosevelt campaigned on the Progressive Party ticket for national health insurance (NHI), together with women’s suffrage, safe conditions for industrial workers and other social issues.  This would have been consistent with a trend over the previous 30 years in many European countries to establish one form or another of social health insurance.  Although Roosevelt lost the election to Woodrow Wilson, progressives continued to push for NHI over the next few years.  Several states, including Massachusetts, New York and California, introduced health insurance bills during those years, and Congress held hearings in 1916 on a federal plan to provide disability and sickness benefits.

Some reform groups, including a strong American Association of Labor Legislation, advocated energetically for NHI.  But as the public debate proceeded, some of the initial proponents for NHI developed conflicting positions.  Organized labor, for example, later sided more with business.  Then with a sudden shift of the country’s priorities with our entry into World War I, the proposal was defeated in 1917 by a powerful alliance between business and organized medicine.

Second Attempt: 1932-1938

The 1920’s saw a growing concern across the country about the rising costs of health care.  As a result, an independent commission was established with private funding, the Committee on the Costs of Medical Care (CCMC), including economists, physicians and public health professionals.  For a growing number of families during those Great Depression years, average family costs of care ($250/year) consumed one-third or more of their annual income.  Chaired by Dr. Ray Lyman Wilbur, the Commission issued an influential interim report in 1932, The Economics of Public Health and Medical Care, calling for “a new approach to health insurance because the costs of medical care now involve larger sums of money and affect more people than does wage-loss due to sickness.”

As the CCMC led the charge for NHI, the American Medical Association (AMA) quickly denounced it as socialism.  President Franklin D. Roosevelt had already taken on the special interests in enacting the Glass-Steagall Act, divesting Wall Street investment houses of banking functions, and by establishing the Tennessee Valley Authority to provide cheap electric power in the South.  He was reluctant, however, to take on the AMA over NHI.  The AMA was a much more consolidated and powerful group than it is today, so the New Deal went ahead with Social Security without NHI.  Of special interest today, however, is that FDR was fully prepared to fight for legislation without a bipartisan approach.  In her classic biography, FDR, Jean Edward Smith, Professor of Political Science at Marshall University, describes how FDR relished the hatred of the special interests, whom he called “economic royalists,” and waged class warfare without apology as long as he knew he had a majority of the public on his side.

Third Attempt: 1945-1950

While postponing action on NHI during the 1930’s, FDR did not abandon the idea.  He put it back on the legislative agenda in his 1944 State of the Union message, asking Congress for an “economic bill of rights” to include a plan for adequate medical care.  After FDR died in April 1945, President Harry Truman proposed a compulsory plan for comprehensive NHI, together with increased hospital construction and doubling the numbers of physicians and nurses nationwide.  NHI was to be administered through the Social Security program, and its provisions were incorporated into the Wagner-Murray-Dingell bill in Congress.

Battle lines over the latest proposal for NHI were quickly drawn, pitting the AMA and the American Hospital Association (AHA) against progressives and the Committee on the Nation’s Health, an ad hoc group of liberals and union leaders.  While President Truman attempted to reassure opponents that the program would not be socialized medicine and that “people would get medical and hospital services just as they do now,” opponents demonized the bill as socialism.  The AMA went so far as to claim the NHI would “turn physicians into slaves,” proposing instead an expansion of voluntary health insurance and indigent care services.
The AMA and AHA led a well-funded campaign against the bill, joining with large corporations, the American Bar Association, the Chamber of Commerce, and community organizations in the effort.  Most of the country’s press was sympathetic to the opposition.  As the acrimonious debate wore on, public attitudes toward NHI, while favorable among 58% of the public in 1945, eroded in later surveys as a majority of people turned to favor voluntary health insurance.  The third attempt to enact NHI lost public and legislative support as the nation entered the Korean War.

Fourth Attempt: 1971-1974

 Health insurance returned to the national stage in 1971 when President Richard Nixon proposed an employer mandate, a “play or pay” plan requiring employers to either provide a minimal level of health insurance coverage to their employees or pay a tax that would finance their coverage from an insurance pool that would also cover the unemployed.  That plan would have also placed a ceiling on out-of-pocket health care expenses and eliminated exclusions based on pre-existing conditions.  In addition, it called for the widespread adoption of health maintenance organizations (HMOs) with the goal to cover 90% of the population by 1980.  An accompanying “Family Health Insurance Program” would have subsidized basic coverage for low-income families, thereby replacing Medicaid.  Senator Edward M. Kennedy counter-proposed the “Health Security Act,” a single-payer public financing system for universal coverage of all Americans.  True to form, the AMA put forward its own Medicredit proposal, which would have provided tax credits to help people buy their own private insurance.

These proposals generated furious debate.  Liberals considered the Nixon proposal a windfall for the private insurance industry that fell short of universal coverage by 20-40 million people, while conservatives held out for a much more limited role of government.  A compromise proposal was forged between Kennedy and Representative Wilbur Mills (D-AR), the powerful Chairman of the House Ways and Means Committee, which would have required co-payments of 25% and put an annual cap of $1,000 on health care payments by individuals or families.

While the Kerr-Mills bill came quite close to passage, other events soon claimed the country’s attention, especially the Vietnam War, Watergate, and Mills’ personal scandal.  Instead, the Health Maintenance Organization Act was finally passed in December 1973, setting aside $375 million for a five-year demonstration project to test the feasibility of HMOs.  This was followed the next year by the Employee Retirement Income Security Act (ERISA), which exempted large corporations’ self-insured health plans from state regulations.

Fifth Attempt: 1993-1994

Although Jimmy Carter campaigned for NHI during the 1976 presidential elections, health care soon lost its priority on the national agenda as the country was forced to deal with a recession and inflation.  President Carter’s loss to Ronald Reagan in 1980 ushered in a new time of conservative dominance, accompanied by a resurgence of corporatization of market-based health care with little regulation.  Reagan’s philosophy had been clearly enunciated 20 years earlier: “Medicare is not just the first step toward a government takeover of medicine, but the imposition of socialism throughout the economy.”

Health care was not to regain a leading place on the national agenda until the 1990’s.  Health care reform re-emerged during the 1992 election cycle as a high priority issue.  By the early 1990’s, competition had become the great hope to control increasing costs, decreased access, and variable quality in our market-based system.  Many hoped that a reorganized system could induce more competition within a more regulated insurance industry and lead toward universal coverage.

1993 opened with a flurry of activity and renewed energy toward developing legislative proposals for universal coverage.  President Bill Clinton appointed his wife, Hilary Rodham Clinton, as chairperson of the Health Care Task Force, which was carefully selected from the insurance industry and business, who were chiefly responsible for the problems of the existing system.  Proceedings of the Task Force were held behind closed doors, and little input was sought from either the health professions or the public policy community.

After heated controversy among the Task Force members involving divisions within and between insurance and business interests, the American Health Security Act emerged in Congress as the Clinton Health Plan (CHP).  It was soon joined in the legislative hopper by five other competing proposals.  Four of the proposals, two Democratic and two Republican, were variants of managed competition, while the fifth was a single payer plan modeled after the Canadian [Medicare] system.

As the battles ensued among the competing stakeholders and their lobbyists, and as more specifics became known about each of the proposals, legislative support melted away for any of the plans.  In 1994, the CHP died in committee without getting to a floor vote.  HR 3222 was the only proposal with bipartisan support, but not anywhere enough for passage.  The single payer proposal (HR 1200) attracted the largest number of supporters in Congress and was the only one to pass out of committee, but it was soon marginalized by lobbyists and ridiculed by the major corporate media as too “extreme” or “utopian.”

The CHP was criticized from most quarters as too complex, too expensive, and poorly conceived.  It was seen as a sell-out to the private insurance industry, and dubbed by some observers as the “Health Insurance Industry Preservation Act.”  The final bill was 1,342 pages in length, and it became too confusing for the public and many legislators to understand.  A political debacle for the Clinton administration, its defeat was attributed to lack of support within the working middle class, concern about increased taxes, and growing anti-government resentment.  With the exception of two minor incremental system changes, the failure of health care reform in 1994 put a stop to further efforts for the next 15 years.   

Sixth Attempt: 2008-2011

To be written

A Proposal for Free Universal Health Care, 1714

John Bellers (1654-1725), a wealthy London Quaker cloth merchant, advocated for a state-funded health care system along with medical research in 1714. An Essay Towards the Improvement of Physick was dedicated to Parliament, and had sections addressed to physicians, the South-Sea Company, and the Lord Mayor and governing body of London. Although this was not the first such state health care proposal, it was the first clearly articulated and masterfully argued, with strong appeals to the self-interest of the wealthy.

Bellers is best known for his communal scheme to eliminate poverty. Here, as a “health economist,” he estimated that a hundred thousand people, mostly poor, died each year due to a lack of healthcare.
 
According to his calculations, each laborer lost would cost the economy 200 pounds; this is his justification for state funding.

He proposed that hospitals be build for the poor in London (as a start) and other major centers, and that smaller communities be provided with a physician and a surgeon. Hospitals would also serve as training centers and places where knowledge about successful treatments and medicines could be gathered. Teaching hospitals would be set up in Oxford and Cambridge. Laboratories would be established to develop and test medicines, and a global search would be conducted for new medicines. Specialized hospitals would be set up for the blind.

To appeal to those who could influence the introduction of such a scheme, he points out that the wealthy would also benefit from the advances made in medical knowledge. They also die for lack of knowledge: “And who knows whether Himself, a favorite Daughter, or his only Son, the Heir and Hopes of his Family, may not be of that Number?” And of course, he includes moral arguments: that the state must not ignore the needs of the people and that the government should be responsible to form oversight committees for the system.
 
Bellers’ insights went well beyond any vision of his contemporaries. When he died of a long-term stomach ailment, there was no developed medical establishment to save him.

 Site Updated:
July 23, 2012

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