Three Generations of Reform Proposals
“Today’s problems were yesterday’s solution’s.”
—former Senator Sam Nunn (D, GA)
Health reform proposals have a century-long history. Present promises should be viewed through the lens of what has been tried, and not tried, before.
In the mid-20th century, when America had recently won World War II, the Social Security program was new and faith in the government was at historic highs, there were sustained efforts to graft a national health policy on Social Security. Franklin Roosevelt demurred, considering it a policy too far, but Harry Truman bet his presidency on it. He lost the policy fight, but kept the presidency. John F. Kennedy failed but Lyndon Johnson succeeded to enacting federally funded health care for seniors.
During the several decades of wrangling over Federally funded health care, the private system evolved. Health insurance was first offered to groups beginning in the 1920s. By World War II, large employers embraced health benefits as one of the few ways to compete for scarce labor. Our present employer-based system grew rapidly in the middle decades of the 20th century, and unions’ enthusiasm for national insurance faded after they had secured coverage at the labor bargaining table.
By the late 20th century, the flaws in this system were readily apparent. So was disenchantment with government. Although a Republican president, Richard Nixon, took up the mantle of national health insurance, as did Jimmy Carter a few years later, both were criticized as insufficiently aggressive and blocked by the same potential challenger for the White House, Ted Kennedy.
But throughout long periods of government inactivity, health inflation—often as much as three times the rate of growth in overall consumer prices—pressed on American households. Health care became so expensive that to be uninsured meant being undoctored. Health reform was central to Bill Clinton’s successful presidential run in 1992 and Barack Obama’s in 2008. But the conservative revolution of the 1980s rendered a full-scale federalization of health care politically impossible. These reforming presidents limited themselves to expanded regulation of employers and the insurance industry, leading to an insurance mandate on individuals. Clinton’s reform died stillborn in 1994. Obama’s Affordable Care Act borrowed heavily from it, including a political strategy that coopted key opponents to ensure passage—and several rounds of Supreme Court litigation.
These short chapters offer a very telegraphic tour of the spotty record of health reform over the past 100 years, from the Progressive Era to Obamacare. We will skip lightly and quickly, especially over the distant past. We will expand a bit for Hillarycare in the 1990s, because its political failure informed the Obamacare do-over in the late 2000s.
Presidential candidates often fall victim to the false belief that history began only with their campaign. Health reform did not begin with the ACA. It has been a locus of political maneuvering, and has helped shape the occupant of the White House, for over a dozen presidencies.