On March 23, 2016, we recognized the sixth anniversary of the signing of the Patient Protection and Affordable Care Act (ACA), a law designed to increase the number of Americans covered by health insurance and decrease the cost of health care. Prior to and since its passage, many have criticized the ACA as too costly and too quickly implemented (indeed, some would say, implemented without much planning or thought). Others have denigrated it as a step toward “socialized medicine” or as “big government”—a historically distrusted approach to solving problems.
As a student of health policy, I have watched the yarn of attempts to enact a comprehensive health insurance system ravel and unravel with each administration. Yes, for decades, political parties have staunchly opposed this type of program to reform our ailing system. But why is there such resistance to government involvement in health care reform?
This hasn’t been limited to insurance. Since the mid-1800s, despite the known dangers (including death) of various contagious diseases (eg, smallpox, malaria), people have resisted, even vehemently opposed, government-initiated regulations intended to combat such illnesses.1 Yet, today, we recognize that many improvements in the health of our communities and ourselves are founded on the infrastructure of the public health system. In most cities and states, the public health department responds to everyday health threats and emergencies through programs and initiatives that are government sponsored and funded—and accepted (one might even say expected) by most of us. Dare I point out that these are part of a “social insurance” program?
The idea of a comprehensive approach to health care coverage is not new. One of the earliest government interventions toward social insurance was the 1921 Sheppard-Towner Act, which provided matching funds to states for prenatal and child health centers. Regrettably, it was viewed by the AMA as “excessive federal interference in local health concerns” and discontinued a mere six years later.1
A later intervention, the Hill-Burton Act (passed in 1946) provided hospitals, nursing homes, and other health facilities with grants and loans for construction and modernization.2 An obligation tied to receiving funds was the requirement that administrators of the facilities “provide a reasonable volume of services to persons unable to pay and to make their services available to all persons residing in the facility’s area.”2 One could posit that these two policies influenced the movement toward national insurance in the United States.
We have a patchwork quilt of a health insurance system that includes social insurance programs: Social Security and Medicare. Generations of Americans have contributed to those programs through taxes and expect to benefit from them. And for generations—actually a century—there have been attempts to establish national health insurance (NHI) in the US. In the early 1900s, after Germany and England established health insurance for industrial workers, progressive social reformers attempted to secure similar protection for American workers but were unsuccessful.3 Repeated efforts in 1948, 1965, 1974, 1978, and 1994 also failed to institute an NHI program.
But why? There has been public support for some form of comprehensive NHI since the 1930s. The percentage of Americans expressing support for more government intervention on health care delivery has not fallen below 60% since 1937.4 This disconnect between the people’s desires and politics has been analyzed extensively and written about in many health policy texts.
So when did the idea of NHI become palatable? The notion came closer to reality during the Clinton administration. As the political parties began to fragment, they lost their power over health care politics. With more than 30 million Americans either without health insurance, or in jeopardy of losing what they had, the push for reform was stronger than ever before. We came close, but the scare tactics by NHI opponents about cost, decreased benefits, and increased risk (remember the Harry and Louise commercials?) quickly put the kibosh on that attempt at reform.
Continue forward to 2009 >>