The Long History of American Health-Care Fights: Echoes

A poll of Americans revealed that 68 percent thought it would be "a good idea" to introduce a national health-care system. "These American consumers," concluded one commentator, "are so ready for reform of the structure and economics of medicine that they are willing to effect it by compulsion."

One more skirmish in the ongoing fight over Obamacare? Not quite: This observation was written in 1944. The clash over whether the federal government should be involved in health care -- now being argued before the Supreme Court -- has deep roots in U.S. history. Much of the same rhetoric and many of the same epithets were hurled back and forth in the first chapter of this saga, which took place in the 1940s.

While European nations, beginning with Germany in 1883, were introducing compulsory sickness insurance, among other social-welfare programs, the U.S. left the matter to the states, which in turn generally left it to private philanthropy and voluntary organizations. Despite rising concern over the cost and availability of medical care in the 1920s, only a few attempts were made to increase government support, and none succeeded.

These early efforts did, however, arouse the wrath of the American Medical Association, which, early on, began to denounce anything that smacked of health-care reform as "socialistic" and "communistic." From the first, too, many doctors disagreed with the AMA.

Social-welfare legislation at the national level first entered American life with President Franklin D. Roosevelt’s New Deal, in the 1930s. But in the midst of the Great Depression, the emphasis was on unemployment insurance and old-age pensions. The Social Security Act of 1935 omitted health insurance because its supporters feared that inclusion might sink the bill.

In 1939, Senator Robert Wagner, a Democrat of New York and an ardent supporter of health insurance, introduced a "national health bill," but it went nowhere. In 1943, a new bill sponsored by Wagner, Senator James Murray of Montana and Representative John Dingell of Michigan sparked the first major debate over the federal role in medicine.

The bill proposed to extend Social Security to cover hospitalization and related medical care with a 3 percent tax on all wages and salaries up to $3,000 a year. It would institute compulsory medical and hospital insurance for everyone covered by the old-age and survivors’ provisions of the Social Security Act, their dependents, and some 15 million others.

"The question," wrote the conservative Saturday Evening Post in September 1943, "is whether the undoubted needs of people who lack adequate medical care cannot be taken care of at a social cost lower than the ‘co-ordination’ of all medical service under Government aegis."

The debate hasn't shifted very far from that question in the seven decades since.

Doctors at the time opposed the bill because they believed it would impose a death sentence on private practice, politicize medicine and turn health service into a government bureaucracy.

Advocates pointed to the dismal state of national health: The wartime draft had rejected a shocking 4 million men -- a third of those called to serve -- as physically or mentally unfit. About one in six Americans had a chronic disease or physical impairment. Some 95 percent needed dental care, 30 percent of them badly.

But their treatment options were limited. Rural regions lacked enough doctors and medical facilities, especially after the military called about a third of U.S. physicians to duty. In 1942, almost 2.4 million people were disabled in industrial accidents, creating more casualties at home than on the battlefield. And large numbers couldn't afford medical attention: The 1935-36 National Health Survey found that 90 percent of Americans couldn't pay for adequate medical and hospital care by the usual fee-for-service methods.

Private health-insurance organizations, such as Blue Cross, existed, but on a small scale. Many doctors favored the idea of group practices that would pay them a salary, but the American Medical Association continued to denounce any structural change in the field as "socialism and communism inciting to revolution," and threatened doctors with expulsion from medical societies if they cooperated with any version of group practice combined with prepayment.

Overlooked in the debate was the degree to which government was already involved in medicine. States licensed physicians and to some extent regulated medical practice. The federal government indirectly subsidized some medical expenses by allowing them as tax write-offs. States disbursed an estimated $100 million a year in medical benefits under workers’ compensation laws. Beginning with the New Deal, government money underwrote much of the investment in hospitals. The blind, the disabled, the mentally ill and others received treatment with public assistance. And most importantly, public-health programs at both the national and state levels did vital work in warding off epidemics and other ills.

Most federal funding, however, took the form of grants-in-aid to states rather than direct payments. The Wagner-Murray-Dingell bill increased Washington’s role in two key respects: It made health insurance compulsory, and it gave authority over the system to a federal agency.

The bill thus ignited what would become a perpetual clash over compulsory versus voluntary action, and it raised concerns even among some supporters that the country simply lacked enough medical personnel and facilities to carry out such a program. The bill died in committee.

In 1945, President Harry S. Truman put the administration’s full weight behind a revised version. There followed a five-year struggle in which national health insurance moved to the center of the political stage. Ultimately Truman lost the battle and considered it one of his biggest disappointments.

The issue found new life with the passage of Medicare and Medicaid in 1965 -- concentrating on the elderly and the poor gave it broader public support. But, 47 years later, the fight over a full-fledged national health-insurance system goes on.

(Maury Klein is a professor of history emeritus at the University of Rhode Island and the author of 16 books on American history. The opinions expressed are his own.)

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