13 Jan Revolutionary Influences 200 words total Prior to beginning work on this discussion, review your textbook chapters for this w
Week 1 Discussion 2: Revolutionary Influences 200 words total
Prior to beginning work on this discussion, review your textbook chapters for this week and read the article The History of Healthcare Quality: The First 100 Years 1860–1960 and review Healthcare Timeline (Links to an external site.) and A Brief History: Universal Health Care Efforts in the US (Links to an external site.) and A Brief History: Universal Health Care Efforts in the US (Links to an external site.).
Chapter 2 in your textbook discusses the evolution of our health care system. Much of it evolved due to the political landscape, societal constraints, consumer demand, escalating costs, and technological advancement. Legislation and legal cases also influenced the health care system considerably. After reading Chapter 2 in your textbook, review the time line simulation Global Perspectives: Shifts in Science and Medicine That Changed Healthcare (Links to an external site.) in the Summary and Resources page.
Consider how the U.S. health care system has evolved over the past 50 years. In your post,
- Choose one of the influencing factors from the Global Perspectives: Shifts in Science and Medicine That Changed Healthcare time line and discuss its impact on the health care system.
- Rationalize why your chosen influencing factor has been revolutionary for the health care system.
A Brief History: Universal Health Care Efforts in the US (Transcribed from a talk given by Karen S. Palmer MPH, MS in San
Francisco at the Spring, 1999 PNHP meeting)
Late 1800’s to Medicare
The campaign for some form of universal government-funded health care
has stretched for nearly a century in the US On several occasions,
advocates believed they were on the verge of success; yet each time they
faced defeat. The evolution of these efforts and the reasons for their failure
make for an intriguing lesson in American history, ideology, and character.
Other developed countries have had some form of social insurance (that
later evolved into national insurance) for nearly as long as the US has been
trying to get it. Some European countries started with compulsory sickness
insurance, one of the first systems, for workers beginning in Germany in
1883; other countries including Austria, Hungary, Norway, Britain, Russia,
and the Netherlands followed all the way through 1912. Other European
countries, including Sweden in 1891, Denmark in 1892, France in 1910, and
Switzerland in 1912, subsidized the mutual benefit societies that workers
formed among themselves. So for a very long time, other countries have
had some form of universal health care or at least the beginnings of it. The
primary reason for the emergence of these programs in Europe was
income stabilization and protection against the wage loss of sickness
rather than payment for medical expenses, which came later. Programs
were not universal to start with and were originally conceived as a means
of maintaining incomes and buying political allegiance of the workers.
In a seeming paradox, the British and German systems were developed by
the more conservative governments in power, specifically as a defense to
counter expansion of the socialist and labor parties. They used insurance
against the cost of sickness as a way of “turning benevolence to power”.
US circa 1883-1912, including Reformers and the Progressive Era:
What was the US doing during this period of the late 1800’s to 1912? The
government took no actions to subsidize voluntary funds or make sick
insurance compulsory; essentially the federal government left matters to
the states and states left them to private and voluntary programs. The US
did have some voluntary funds that provided for their members in the case
of sickness or death, but there were no legislative or public programs
during the late 19th or early 20th century.
In the Progressive Era, which occurred in the early 20th century, reformers
were working to improve social conditions for the working class. However
unlike European countries, there was not powerful working class support
for broad social insurance in the US The labor and socialist parties’ support
for health insurance or sickness funds and benefits programs was much
more fragmented than in Europe. Therefore the first proposals for health
insurance in the US did not come into political debate under anti-socialist
sponsorship as they had in Europe.
Theodore Roosevelt 1901 — 1909
During the Progressive Era, President Theodore Roosevelt was in power
and although he supported health insurance because he believed that no
country could be strong whose people were sick and poor, most of the
initiative for reform took place outside of government. Roosevelt’s
successors were mostly conservative leaders, who postponed for about
twenty years the kind of presidential leadership that might have involved
the national government more extensively in the management of social
AALL Bill 1915
In 1906, the American Association of Labor Legislation (AALL) finally led
the campaign for health insurance. They were a typical progressive group
whose mandate was not to abolish capitalism but rather to reform it. In
1912, they created a committee on social welfare which held its first
national conference in 1913. Despite its broad mandate, the committee
decided to concentrate on health insurance, drafting a model bill in 1915. In
a nutshell, the bill limited coverage to the working class and all others that
earned less than $1200 a year, including dependents. The services of
physicians, nurses, and hospitals were included, as was sick pay, maternity
benefits, and a death benefit of fifty dollars to pay for funeral expenses.
This death benefit becomes significant later on. Costs were to be shared
between workers, employers, and the state.
AMA supported AALL Proposal
In 1914, reformers sought to involve physicians in formulating this bill and
the American Medical Association (AMA) actually supported the AALL
proposal. They found prominent physicians who were not only
sympathetic, but who also wanted to support and actively help in securing
legislation. In fact, some physicians who were leaders in the AMA wrote to
the AALL secretary: “Your plans are so entirely in line with our own that we
want to be of every possible assistance.” By 1916, the AMA board approved
a committee to work with AALL, and at this point the AMA and AALL
formed a united front on behalf of health insurance. Times have definitely
changed along the way.
In 1917, the AMA House of Delegates favored compulsory health insurance
as proposed by the AALL, but many state medical societies opposed it.
There was disagreement on the method of paying physicians and it was
not long before the AMA leadership denied it had ever favored the
AFL opposed AALL Proposal
Meanwhile the president of the American Federation of Labor repeatedly
denounced compulsory health insurance as an unnecessary paternalistic
reform that would create a system of state supervision over people’s
health. They apparently worried that a government-based insurance
system would weaken unions by usurping their role in providing social
benefits. Their central concern was maintaining union strength, which was
understandable in a period before collective bargaining was legally
Private insurance industry opposed AALL Proposal
The commercial insurance industry also opposed the reformers’ efforts in
the early 20th century. There was great fear among the working class of
what they called a “pauper’s burial,” so the backbone of insurance business
was policies for working class families that paid death benefits and
covered funeral expenses. But because the reformer health insurance
plans also covered funeral expenses, there was a big conflict. Reformers
felt that by covering death benefits, they could finance much of the health
insurance costs from the money wasted by commercial insurance policies
who had to have an army of insurance agents to market and collect on
these policies. But since this would have pulled the rug out from under the
multi-million dollar commercial life insurance industry, they opposed the
national health insurance proposal.
WWI and anti-German fever
In 1917, the US entered WWI and anti-German fever rose. The government-
commissioned articles denouncing “German socialist insurance” and
opponents of health insurance assailed it as a “Prussian menace”
inconsistent with American values. Other efforts during this time in
California, namely the California Social Insurance Commission,
recommended health insurance, proposed enabling legislation i
n 1917, and then held a referendum. New York, Ohio, Pennsylvania, and
Illinois also had some efforts aimed at health insurance. But in the Red
Scare, immediately after the war, when the government attempted to root
out the last vestiges of radicalism, opponents of compulsory health
insurance associated it with Bolshevism and buried it in an avalanche of
anti-Communist rhetoric. This marked the end of the compulsory national
health debate until the 1930’s.
Why did the Progressives fail?
Opposition from doctors, labor, insurance companies, and business
contributed to the failure of Progressives to achieve compulsory national
health insurance. In addition, the inclusion of the funeral benefit was a
tactical error since it threatened the gigantic structure of the commercial
life insurance industry. Political naivete on the part of the reformers in
failing to deal with the interest group opposition, ideology, historical
experience, and the overall political context all played a key role in shaping
how these groups identified and expressed their interests.
There was some activity in the 1920’s that changed the nature of the
debate when it awoke again in the 1930’s. In the 1930’s, the focus shifted
from stabilizing income to financing and expanding access to medical care.
By now, medical costs for workers were regarded as a more serious
problem than wage loss from sickness. For a number of reasons, health
care costs also began to rise during the 1920’s, mostly because the middle
class began to use hospital services and hospital costs started to increase.
Medical, and especially hospital, care was now a bigger item in family
budgets than wage losses.
Next came the Committee on the Cost of Medical Care (CCMC). Concerns
over the cost and distribution of medical care led to the formation of this
self-created, privately funded group. The committee was funded by 8
philanthropic organizations including the Rockefeller, Millbank, and
Rosenwald foundations. They first met in 1926 and ceased meeting in 1932.
The CCMC was comprised of fifty economists, physicians, public health
specialists, and major interest groups. Their research determined that there
was a need for more medical care for everyone, and they published these
findings in 26 research volumes and 15 smaller reports over a 5-year
period. The CCMC recommended that more national resources go to
medical care and saw voluntary, not compulsory, health insurance as a
means to covering these costs. Most CCMC members opposed
compulsory health insurance, but there was no consensus on this point
within the committee. The AMA treated their report as a radical document
advocating socialized medicine, and the acerbic and conservative editor of
JAMA called it “an incitement to revolution.”
FDR’s first attempt — failure to include in the Social Security Bill of 1935
Next came Franklin D. Roosevelt (FDR), whose tenure (1933-1945) can be
characterized by WWI, the Great Depression, and the New Deal, including
the Social Security Bill. We might have thought the Great Depression
would create the perfect conditions for passing compulsory health
insurance in the US, but with millions out of work, unemployment
insurance took priority followed by old age benefits. FDR’s Committee on
Economic Security, the CES, feared that inclusion of health insurance in its
bill, which was opposed by the AMA, would threaten the passage of the
entire Social Security legislation. It was therefore excluded.
FDR’s second attempt — Wagner Bill, National Health Act of 1939
But there was one more push for national health insurance during FDR’s
administration: The Wagner National Health Act of 1939. Though it never
received FDR’s full support, the proposal grew out of his Tactical
Committee on Medical Care, established in 1937. The essential elements of
the technical committee’s reports were incorporated into Senator
Wagner’s bill, the National Health Act of 1939, which gave general support
for a national health program to be funded by federal grants to states and
administered by states and localities. However, the 1938 election brought a
conservative resurgence and any further innovations in social policy were
extremely difficult. Most of the social policy legislation precedes 1938. Just
as the AALL campaign ran into the declining forces of progressivism and
then WWI, the movement for national health insurance in the 1930’s ran
into the declining fortunes of the New Deal and then WWII.
About this time, Henry Sigerist was in the US He was a very influential
medical historian at Johns Hopkins University who played a major role in
medical politics during the 1930’s and 1940’s. He passionately believed in a
national health program and compulsory health insurance. Several of
Sigerist’s most devoted students went on to become key figures in the
fields of public health, community and preventative medicine, and health
care organization. Many of them, including Milton Romer and Milton Terris,
were instrumental in forming the medical care section of the American
Public Health Association, which then served as a national meeting ground
for those committed to health care reform.
Wagner-Murray-Dingell Bills: 1943 and onward through the decade
The Wagner Bill evolved and shifted from a proposal for federal grants-in-
aid to a proposal for national health insurance. First introduced in 1943, it
became the very famous Wagner-Murray- Dingell Bill. The bill called for
compulsory national health insurance and a payroll tax. In 1944, the
Committee for the Nation’s Health, (which grew out of the earlier Social
Security Charter Committee), was a group of representatives of organized
labor, progressive farmers, and liberal physicians who were the foremost
lobbying group for the Wagner-Murray-Dingell Bill. Prominent members of
the committee included Senators Murray and Dingell, the head of the
Physician’s Forum, and Henry Sigerist. Opposition to this bill was enormous
and the antagonists launched a scathing red baiting attack on the
committee saying that one of its key policy analysts, I.S. Falk, was a conduit
between the International Labor Organization (ILO) in Switzerland and the
United States government. The ILO was red-baited as “an awesome
political machine bent on world domination.” They even went so far was to
suggest that the United States Social Security board functioned as an ILO
subsidiary. Although the Wagner-Murray-Dingell Bill generated extensive
national debates, with the intensified opposition, the bill never passed by
Congress despite its reintroduction every session for 14 years! Had it
passed, the Act would have established compulsory national health
insurance funded by payroll taxes.
After FDR died, Truman became president (1945-1953), and his tenure is
characterized by the Cold War and Communism. The health care issue
finally moved into the center arena of national politics and received the
unreserved support of an American president. Though he served during
some of the most virulent anti-Communist attacks and the early years of
the Cold War, Truman fully supported national health insurance. But the
opposition had acquired new strength. Compulsory health insurance
became entangled in the Cold War and its opponents were able to make
“socialized medicine” a symbolic is
sue in the growing crusade against Communist influence in America.
Truman’s plan for national health insurance in 1945 was different than FDR’s
plan in 1938 because Truman was strongly committed to a single universal
comprehensive health insurance plan. Whereas FDR’s 1938 program had a
separate proposal for medical care of the needy, it was Truman who
proposed a single egalitarian system that included all classes of society,
not just the working class. He emphasized that this was not “socialized
medicine.” He also dropped the funeral benefit that contributed to the
defeat of national insurance in the Progressive Era. Congress had mixed
reactions to Truman’s proposal. The chairman of the House Committee
was an anti-union conservative and refused to hold hearings. Senior
Republican Senator Taft declared, “I consider it socialism. It is to my mind
the most socialistic measure this Congress has ever had before it.” Taft
suggested that compulsory health insurance, like the Full Unemployment
Act, came right out of the Soviet constitution and walked out of the
hearings. The AMA, the American Hospital Association, the American Bar
Association, and most of then nation’s press had no mixed feelings; they
hated the plan. The AMA claimed it would make doctors slaves, even
though Truman emphasized that doctors would be able to choose their
method of payment.
In 1946, the Republicans took control of Congress and had no interest in
enacting national health insurance. They charged that it was part of a large
socialist scheme. Truman responded by focusing even more attention on a
national health bill in the 1948 election. After Truman’s surprise victory in
1948, the AMA thought Armageddon had come. They assessed their
members an extra $25 each to resist national health insurance, and in 1945
they spent $1.5 million on lobbying efforts which at the time was the most
expensive lobbying effort in American history. They had one pamphlet that
said, “Would socialized medicine lead to socialization of other phases of
life? Lenin thought so. He declared socialized medicine is the keystone to
the arch of the socialist state.” The AMA and its supporters were again very
successful in linking socialism with national health insurance, and as anti-
Communist sentiment rose in the late 1940’s and the Korean War began,
national health insurance became vanishingly improbable. Truman’s plan
died in a congressional committee. Compromises were proposed but none
were successful. Instead of a single health insurance system for the entire
population, America would have a system of private insurance for those
who could afford it and public welfare services for the poor. Discouraged
by yet another defeat, the advocates of health insurance now turned
toward a more modest proposal they hoped the country would adopt:
hospital insurance for the aged and the beginnings of Medicare.
After WWII, other private insurance systems expanded and provided
enough protection for groups that held influence in American to prevent
any great agitation for national health insurance in the 1950’s and early
1960’s. Union-negotiated health care benefits also served to cushion
workers from the impact of health care costs and undermined the
movement for a government program.
Why did these efforts for universal national health insurance fail again?
For may of the same reasons they failed before: interest group influence
(code words for class), ideological differences, anti-communism, anti-
socialism, fragmentation of public policy, the entrepreneurial character of
American medicine, a tradition of American voluntarism, removing the
middle class from the coalition of advocates for change through the
alternative of Blue Cross private insurance plans, and the association of
public programs with charity, dependence, personal failure and the
almshouses of years gone by.
For the next several years, not much happened in terms of national health
insurance initiatives. The nation focussed more on unions as a vehicle for
health insurance, the Hill-Burton Act of 1946 related to hospital expansion,
medical research and vaccines, the creation of national institutes of health,
and advances in psychiatry.
Johnson and Medicare/caid
Finally, Rhode Island congressman Aime Forand introduced a new
proposal in 1958 to cover hospital costs for the aged on social security.
Predictably, the AMA undertook a massive campaign to portray a
government insurance plan as a threat to the patient-doctor relationship.
But by concentrating on the aged, the terms of the debate began to
change for the first time. There was major grass roots support from seniors
and the pressures assumed the proportions of a crusade. In the entire
history of the national health insurance campaign, this was the first time
that a ground swell of grass roots support forced an issue onto the national
agenda. The AMA countered by introducing an “eldercare plan,” which was
voluntary insurance with broader benefits and physician services. In
response, the government expanded its proposed legislation to cover
physician services, and what came of it were Medicare and Medicaid. The
necessary political compromises and private concessions to the doctors
(reimbursements of their customary, reasonable, and prevailing fees), to
the hospitals (cost plus reimbursement), and to the Republicans created a
3-part plan, including the Democratic proposal for comprehensive health
insurance (“Part A”), the revised Republican program of government
subsidized voluntary physician insurance (“Part B”), and Medicaid. Finally, in
1965, Johnson signed it into law as part of his Great Society Legislation,
capping 20 years of congressional debate.
What does history teach us? What is the movement reacting to?
1. Henry Sigerist reflected in his own diary in 1943 that he “wanted to use
history to solve the problems of modern medicine.” I think this is,
perhaps, a most important lesson. Damning her own naivete, Hillary
Clinton acknowledged in 1994 that “I did not appreciate how
sophisticated the opposition would be in conveying messages that
were effectively political even though substantively wrong.” Maybe
Hillary should have had this history lesson first.
2. The institutional representatives of society do not always represent
those that they claim to represent, just as the AMA does not represent
all doctors. This lack of representation presents an opportunity for
attracting more people to the cause. The AMA has always played an
oppositional role and it would be prudent to build an alternative to the
AMA for the 60% of physicians who are not members.
3. Just because President Bill Clinton failed doesn’t mean it’s over. There
have been periods of acquiescence in this debate before. Those who
oppose it can not kill this movement. Openings will occur again. We all
need to be on the lookout for those openings and also need to create
openings where we see opportunities. For example, the focus on
health care costs of the 1980’s presented a division in the ruling class
and the debate moved into the center again. As hockey great Wayne
Gretzky said, “Success is not a matter of skating to where the puck is, it
is a matter of skating to where the puck will be.”
4. Whether we like it or not, we are going to have to deal with the
persistence of the narrow vision of middle class politics. Vincente
Navarro says that the majority opinion of national health insurance has
everything to do with repression and coercion by the capitalist
corporate dominant class. He argues that the conflict and struggles
that continuously take place around the issue of health care unfold
within the parameters of class and that coercion and
repression are forces that determine policy. I think when we talk about
interest groups in this country, it is really a code for class.
5. Red-baiting is a red herring and has been used throughout history to
evoke fear and may continue to be used in these post Cold War times
by those who wish to inflame this debate.
6. Grass roots initiatives contributed in part to the passage of Medicare,
and they can work again. Ted Marmor says that “pressure groups that
can prevail in quiet politics are far weaker in contexts of mass attention
— as the AMA regretfully learned during the Medicare battle.” Marmor
offers these lessons from the past: “Compulsory health insurance,
whatever the details, is an ideological controversial matter that
involves enormous financial and professional stakes. Such legislation
does not emerge quietly or with broad partisan support. Legislative
success requires active presidential leadership, the commitment of an
Administration’s political capital, and the exercise of all manner of
persuasion and arm-twisting.”
7. One Canadian lesson — the movement toward universal health care in
Canada started in 1916 (depending on when you start counting), and
took until 1962 for passage of both hospital and doctor care in a single
province. It took another decade for the rest of the country to catch on.
That is about 50 years all together. It wasn’t like we sat down over
afternoon tea and crumpets and said please pass the health care bill
so we can sign it and get on with the day. We fought, we threatened,
the doctors went on strike, refused patients, people held rallies and
signed petitions for and against it, burned effigies of government
leaders, hissed, jeered, and booed at the doctors or the Premier
depending on whose side they were on. In a nutshell, we weren’t the
sterotypical nice polite Canadians. Although there was plenty of
resistance, now you could more easily take away Christmas than
health care, despite the rhetoric that you may hear to the contrary.
8. Finally there is always hope for flexibility and change. In researching
this talk, I went through a number of historical documents and one of
my favorite quotes that speaks to hope and change come from a 1939
issue of Times Magazine with Henry Sigerist on the cover. The article
said about Sigerist: “Students enjoy his lively classes, for Sigerist does
not mind expounding his dynamic conception of medical history in
hand-to-hand argument. A student once took issue with him and
when Dr. Sigerist asked him to quote his authority, the student
shouted, “You yourself said so!” “When?” asked Dr. Sigerist. “Three
years ago,” answered the student. “Ah,” said Dr. Sigerist, “three years is
a long time. I’ve changed my mind since then.” I guess for me this
speaks to the changing tides of opinion and that everything is in flux
and open to renegotiation.
Special thanks to medical historians and PNHP colleagues Corinne Sutter-
Brown and Ted Brown for background information, critical analysis, and
Much of this talk was paraphrased/annotated directly from the sources
below, in particular the work of Paul Starr:
1. Bauman, Harold, “Verging on National Health Insurance since 1910” in
Changing to National Health Care: Ethical and Policy Issues (Vol. 4,
Ethics in a Changing World) edited by Heufner, Robert P. and Margaret
# P. Battin, University of Utah Press, 1992.
2. “Boost President’s Plan”, Washington Post, p. A23, February 7, 1992.
Brown, Ted. “Isaac Max Rubinow”, (a biographical sketch), American
Journal of Public Health, Vol. 87, No. 11, pp. 1863-1864, 1997
3. Danielson, David A., and Arthur Mazer. “The Massachusetts
Referendum for a National Health Program”, Journal of Public Health
Policy, Summer 1986.
4. Derickson, Alan. “The House of Falk: The Paranoid Style in American
House Politics”, American Journal of Public Health”, Vol. 87, No. 11, pp.
1836 – 1843, 1997.
5. Falk, I.S. “Proposals for National Health Insurance in the USA: Origins
and Evolution and Some Perspectives for the Future’, Milbank
Memorial Fund Quarterly, Health and Society, pp. 161-191, Spring 1977.
6. Gordon, Colin. “Why No National Health Insurance in the US? The
Limits of Social Provision in War and Peace, 1941-1948”, Journal of
Policy History, Vol. 9, No. 3, pp. 277-310, 1997.
7. “History in a Tea Wagon”, Time Magazine, No. 5, pp. 51-53, January 30,
8. Marmor, Ted. “The History of Health Care Reform”, Roll Call, pp. 21,40,
July 19, 1993.
9. Navarro, Vicente. “Medical History as a Justification Rather than
Explanation: Critique of Starr’s The Social Transformation of American
Medicine” International Journal of Health Services, Vol. 14, No. 4, pp.
10. Navarro, Vicente. “Why Some Countries Have National Health
Insurance, Others Have National Health Service, and the United States
has Neither”, International Journal of Health Services, Vol. 19, No. 3, pp.
11. Rothman, David J. “A Century of Failure: Health Care Reform in
America”, Journal of Health Politics, Policy and Law”, Vol. 18, No. 2,
12. Rubinow, Isaac Max. “Labor Insurance”, American Journal of Public
Health, Vol. 87, No. 11, pp. 1862 – 1863, 1997 (Originally published in
Journal of Political Economy, Vol. 12, pp. 362-281, 1904).
13. Starr, Paul. The Social Transformation of American Medicine: The rise
of a sovereign profession and the making of a vast industry. Basic
14. Starr, Paul. “Transformation in Defeat: The Changing Objectives of
National Health Insurance, 1915-1980”, American Journal of Public
Health, Vol. 72,
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