Content area
Full Text
In 1915, reformers issued the first major proposal for national health insurance in the United States (see timeline). They believed that America should follow European countries such as Germany and England in securing access to medical care for workers and protecting them against the economic burdens of illness. The leadership of the American Medical Association (AMA) initially agreed, and the prospects for reform appeared promising.
Yet by 1920, the health care reform campaign had failed, the victim of intense opposition (from businesses and the insurance industry, among others), bad timing (the American entry into World War I), demagoguery, and xenophobia (charges that the health care proposals were “Made in Germany,” “Bolshevik,” and “un-American”). After an internal revolt, the AMA became a steadfast opponent of national health insurance. The issue briefly disappeared from the agenda.1
Nearly 100 years after that first proposal, Americans are still debating health care reform, the perils of “socialized medicine,” and the tensions between individual liberty and government aid. What have been the major developments in U.S. health policy over the past century? And what challenges lie ahead? I focus here on two critical issues, health insurance coverage and cost containment.
Coverage
Political struggles over expanding access to insurance have long defined U.S. health policy. Although proposals focused at first on industrial workers, by the 1940s reformers were seeking a universal health insurance program for all Americans. But universal coverage remained elusive during the 20th century. The same forces that initially stalled national health insurance — resistance from powerful interest groups bent on preserving the status quo, demagoguery, and fear of socialized medicine — endured to undercut subsequent reform efforts. A parade of presidents — including Harry Truman, Richard Nixon, and Bill Clinton — pursued universal coverage.2 They all failed.
That failure is often attributed to a political culture suspicious of centralized power and enamored of individual responsibility. There is no question that the antigovernment strain in U.S. politics made the reformers' task extraordinarily difficult. However, U.S. political institutions represented an equally important — or perhaps even more important — barrier to reform. In the fragmented U.S. system, health care legislation died in Congress even when it enjoyed support from the president and the president's party had majorities in the...