MSJAMA: A historical survey of national health movements and public opinion in the United States.

Abstract

THE UNITED STATES IS THE ONLY INDUSTRIALIZED NATION THAT does not have national health insurance. It has, however, witnessed 5 attempts to achieve it. In the early 1900s, patients paid physicians directly for their services. Concerned that more than a quarter of the population could not afford basic care, the American Association for Labor Legislation (AALL) in 1915 proposed a national insurance system that would cover medical care, sick pay, maternity benefits, and funeral expenses for low-paid workers and their dependents. It would be financed by mandatory employer and employee contributions and additional state funds. Later expanded to cover large segments of the population, the AALL proposal was called a social insurance plan because it would cover only those who paid into it. Opposition from the American Medical Association (AMA), business, and labor, compounded by shifting attitudes and priorities as the United States entered World War I, defeated the proposal. The next movement toward national health insurance came in the 1940s, when senators Robert Wagner and James Murray and Rep John Dingell proposed a plan to expand Social Security, enacted in 1935, to cover physician and hospital care for workers and retirees. Employers and employees would pay into a federal trust fund that would in turn reimburse providers. The unemployed would rely on government assistance or charity care. At the time, 74% of the public favored national health insurance, and 68% liked the idea of Social Security coverage of medical fees. In 1945, President Truman embraced a similar proposal, making him the first president to support national health insurance. Public opinion on the Truman proposal was initially evenly split—38% for and 38% against—but its support by a wide range of legislators and organizations led analysts to predict that it would be passed. The AMA opposed the plan, however, and defeated it with a massive campaign. The first successful push toward national health insurance came in 1965 with the passage of Medicare and Medicaid under President Johnson. At that time, 85% of the elderly were uninsured, and political pressure to cover them was great. Medicare narrowed the Wagner-Murray-Dingle plan to cover only those over 65 with funding from Social Security payments, federal income taxes, and individual premiums. Although Medicare was initially opposed by the AMA, it was supported by 61% of the public. At the same time, Medicaid became the first public assistance program in the national health insurance movement. Public assistance programs are need-based and, unlike social insurance programs, do not require that recipients have paid into them. Medicare and Medicaid are not true national health insurance programs because, unlike similar programs covering the elderly and poor in other nations, they were never expanded to cover all Americans. The 1970s brought a wave of public debate and over a dozen health reform bills, most espousing national health insurance. Two competing proposals, each the first of its kind, stood out. In 1970, Sen Edward Kennedy and Rep Martha Griffiths proposed the first single, universal health insurance program to cover all Americans. The KennedyGriffiths Health Security Program would be funded by employer and employee contributions and federal income taxes. Medicare and Medicaid would be folded into the program. Organized labor supported the bill but the AMA, the insurance industry, and President Nixon opposed it. Like earlier proposals, the Kennedy-Griffiths bill would have replaced the private insurance industry with government-based health insurance. Nixon countered with the first national health insurance plan to maintain the private insurance industry and tie health insurance to employment. Nixon’s plan mandated that employers purchase private insurance policies for their employees. The government would contribute funds to cover the unemployed. With two thirds of the public in support and both Nixon and Kennedy willing to compromise, many thought the passage of national health insurance was imminent. However, congressional delays and the distraction of the Watergate scandal reduced political pressure for national health insurance, and no plan was passed. National health insurance entered public discourse again in the early 1990s, as the number of uninsured in the United States rose from 25 million to 40 million. Voters ranked health care among the top three issues of the 1992 presidential campaign, and two thirds of Americans favored tax-financed national health insurance. President Clinton’s proposal, like Nixon’s, combined mandated employer-based private insurance with governmentfunded public assistance. Clinton’s plan organized payers into a government-regulated system called “managed competition.” Groups of insured would be consolidated into large purchasing cooperatives that would buy insurance for their members, decreasing but not eliminating the number of private insurance companies. Clinton’s plan initially had 59% of the public’s support, but opposition campaigns cut support to 40% in 10 months and reduced momentum for reform. At about the same time, supporters of governmentfinanced national health insurance began calling their pro-