Will We Ever Get National Health Insurance?

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Ms. Quadagno is author of One Nation, Uninsured: Why the U.S. Has No National Health Insurance (Oxford University Press, 2005).

Last year nearly a million more people were uninsured compared to the year before, nearly 48 million in all. The employer-based system that most people of working age have relied on since the 1950s is unraveling at the seams.  Each year for more than a decade the percentage of employers offering health benefits has declined.  The only reason the situation doesn’t look worse is that the government is picking up the slack - through Medicare and Medicaid and through the coverage provided to public employees.

Most uninsured people do not have a regular family doctor and thus do not receive preventive care like cholesterol-lowering drugs or screening for cancer and heart disease.  Frequently the care they do receive is in an emergency room where there are no follow-up services.  Many receive no care at all, because hospitals have been closing in poor neighborhoods where there are large numbers of uninsured people.

The dilemma of the uninsured reverberates throughout the economy, as the cost of their care is borne by taxpayers through government programs or through cost shifting by physicians and hospitals to privately insured patients. Cost shifting, in turn, forces insurance companies to raise premiums. As premiums rise, fewer employers offer coverage.  Some companies have been pushed to the brink of bankruptcy by rising health care costs.

Other nations, regardless of how they raise funds, organize care, and determine eligibility, guarantee every citizen comprehensive coverage for essential health care services.  Most countries allow, and some encourage, private insurance as an upgrade or second tier to a higher class of service and a fuller array of services.  But the practices of these companies are heavily regulated to prevent them from engaging in the sophisticated forms of medical “underwriting” used by insurance companies in the United States to segment people and employee groups into different risk pools.  Underwriting allows insurers to charge more to cover people who have allergies, high blood pressure, depression or arthritis, exclude “preexisting conditions” such as cataracts, asthma, or migraine headaches and deny coverage entirely to older people or people with serious illnesses like AIDS, leukemia, or emphysema.

How did the United States arrive at this vexing dilemma?  This answer is that across the entire span of the 20th century each attempt to enact national health insurance was met with fierce attacks by powerful stakeholders who mobilized their considerable resources to keep the financing of health care a private affair.  In the first half of the century, physicians led the anti-reform coalition, fearful that government entry would mean government control of medical practice and fees.  What allowed physicians to insert their parochial concerns into the political process was the fact that they had the support of powerful allies with greater clout and deeper pockets -- insurance companies, the Chamber of Commerce and the National Association of Manufacturers.

When President Harry Truman made national health insurance the key domestic issue of his Fair Deal, the American Medical Association converted its state and local medical societies into a political machine.  The message promoted in every venue was that national health insurance was socialized medicine, part of a Communist plot to destroy freedom.  The AMA also mobilized politically to defeat Democratic candidates who supported national health insurance.  Doctors, nurses, dentists and office assistants mailed nearly 200,000 letters endorsing Republican candidates who opposed national health insurance. Physicians also sent personal letters to their patients, explaining that there were “evil forces creeping into this country” and asking them to vote for Republican candidates. In the 1950 election six Democratic senators who had supported national health insurance were defeated.

After Medicare was enacted in 1965, physicians learned that they could live with, and indeed profit from, a government program.  After all, the AMA won concessions guaranteeing that the government would not control doctors’ fees or hospital charges and that private insurers would administer Medicare.  As they receded from the battle’s front lines, the insurance industry assumed a leading role against reform. 

When President Bill Clinton proposed a plan, Health Security, to guarantee universal health care coverage in 1992, a coalition of insurers, corporations, and small business groups mobilized against him. At first it seemed Clinton might have some business allies and even support from some large insurance companies.  But when the details of his plan emerged, his allies turned against him.  The most vehement opponent of Health Security was the Health Insurance Association of America.  The HIAA spent more than $15 million in a multi-faceted advertising campaign, sponsored television commercials lambasting health care reform, and formed “swat teams” to write letters and lobby lawmakers.  The effort produced more than 450 thousand contacts with members of Congress, almost a thousand for each senator and congressman.

Insurance agents’ organizations also increased their campaign contributions with the largest sums going to members of the House Ways and Means and Senate Finance Committees, which had jurisdiction over health reform.  They found an ally in the National Federation of Independent Businesses whose members vehemently opposed any legislation that might increase taxes or force them to provide coverage.  Overall, the Center for Public Integrity estimated that 650 organizations spent at least $100 million to defeat the Clinton plan. His supporters raised only $15 million. When the first poll was taken on President Clinton’s plan in September of 1993, 59 percent of the public were in favor.  By June of 1994 public support had declined to only 44 percent.

Since the defeat of the Clinton plan, national health insurance has disappeared from the political agenda.  But polls show that health care is a leading concern of the public, second only to the Iraq war.  Still, the 2008 presidential candidates, for the most part, have been cautious about taking a position on health care reform.  Although all agree that universal coverage should be the goal, the devil is in the details.  Republicans are committed to a solution that relies on increased tax incentives to encourage people to purchase private coverage.  Democrats favor a variety of modest measures – individual and employer mandates, allowing people to buy into health care plans that are similar to federal employee plans, expanding the State Health Insurance Program for uninsured children, and increasing regulations on insurance companies. 

Given the lessons of history, candidates are understandably cautious about advocating a program that would wipe the slate clean and truly guarantee universal coverage.  Yet the public should demand that those who claim they have to capacity to lead the nation take a stand on an issue that is so critical to the well-being of every American family.  If they fail to do so, insurance companies and their allies will continue to control the health care system and ensure that those most in need are least able to obtain coverage.  

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Richard Williams - 7/28/2009

This article is almost as full of misinformation as was Obama's infomercial last week.


Lawrence Brooks Hughes - 7/27/2009

Americans "in favor of some kind of reform" include those in favor of portability, tort reform, and selling health insurance over state lines. It is possible to favor those and other "reforms," without embracing the horrors of a single-payer system. If the left wasn't determined to hold out for the latter, many improvements would be made quickly.

Lajaw Wilson - 8/17/2007

The Constitution of these United States, if followed, will not allow universal health care. I can't believe so many are in favor of such a strong federal government. That was never the intention of the founding fathers.
Let the states develop what they may with no federal oversight to bloat the process.

Kenneth Laurence Davis - 8/12/2007

I don't have a studied opinion, merely an impression, and that is that the reason the EC, while being dominated by liberal market values at least to the same extent as the US, if not more so, still chooses to provide health care for its citizens is that they must have devised an algorithm which shows that this practice improves the bottom line, generally speaking, for a bunch of Somebodies or other. There is no other rationale under the extant market system, which is the true totalitarianism, for doing anything about health care for the lower classes.

The US spends over 15% of GDP on health, as compared to, say, Spain, which spends 8% or so. That difference equates to a lot more money changing hands per capita over here, which is a good thing, of course, if you're in health care. I can't figure out how that EC algorithm works...

Kenneth Davis

Max J. Skidmore - 8/10/2007

Again, Hughes has no argument. He is long on assertion, but short on thought. Obviously, he favors privatizing Social Security, but he doesn't explain why he has the quaint (and wrong) notion that this would be a good thing.

Apparently, he thinks it is sufficient simply to throw out a statement--or in this instance, an implication. Even if Ms Quadagno were mistaken in opposing privatization (which, again, is not the issue here) it is illogical, and in fact absurd, to say that her opinion on Social Security invalidates her opinion on any issue. Mr. Hughes is not only insufferably arrogant, but laughably mistaken.

Hughes goes even farther off on a tangent when he finds my statement (in an unrelated article or in one of my books) that four former presidents ran for the office again. He says that Grant apparently didn't count. Even if I were mistaken, so what? What does that have to do with anything here?

As a matter of fact, though, I was not mistaken. Once more, of course, it is Hughes who is wrong.

In this regard, Grant indeed didn't count. The four I mentioned (Van Buren, Fillmore, Cleveland, and TR) were nominated, and ran races. All received popular votes, and the latter three even received electoral votes.

Grant wasn't nominated, didn't run, and in fact didn't even seek the nomination (although he would have welcomed it). When his wife, Julia, urged him to lobby the convention on his own behalf, he refused, thinking it unseemly. Mr. Hughes could find that in my writings, too.

However, this has absolutely nothing to do with the current discussion. Mr. Hughes apparently becomes so wrought up that he forgets what it is that inspires his ire.

I shall venture a word of advice to Mr. Hughes: he might possibly be at least marginally more persuasive if he were to offer points related to the argument, rather than indiscriminate comments about my statements on other issues.

He may seem fit to reply yet again seeking to make a point (no doubt mentioning something I have written about highways, free speech, music, Hong Kong politics, or a variety of other unrelated matters), but I have devoted too much time to this exchange already. Mr. Hughes is welcome to the last word, if he wishes to continue risking additional exposure.

Lawrence Brooks Hughes - 8/9/2007

Max Skidmore is a professor of political science, and obviously not too sharp on economics. He believes "privatizing Social Security is a terrible idea." (He also wrote an article 1-17-05 claiming that four former presidents had sought the office again, Van Buren, Fillmore, Cleveland and Theodore Roosevelt. The defeat of Ulysses S. Grant on the 36th ballot in the GOP convention of 1880 apparently didn't count...) It seems highly probable Ms. Quadnago agrees with Professor Skidmore about privatization of social security--which would be ample reason to reject out of hand everything she says about health insurance or any other economic matter.

Paul Noonan - 8/9/2007

Actually, it is private employers, not the government that have been the most egregious violators when it comes to regulating private behaviour. There was a story on 60 Minutes a while ago about about a company that fired anyone who smoked, even at home, and did urine tests for nicotine to check up on people. Some states have passed laws to prevent this, many have not.

And there have been numerous cases of employees being disciplined for things they put on the Internet (personal web pages or blogs) even if it had nothing to do with the employer. I remeber a case of a young woman who was told by her boss to remove a picture of herself in a bikini from her webpage, which did not even mention where she worked.

Andrew D. Todd - 8/9/2007

I agree entirely with Max J. Skidmore and Bryan Richard Martin. The HNN trolls are all very young guys, college students and suchlike, and they have no idea how much medical treatment generally hurts. I have an uncomfortable memory of an orthopedics resident trying, unsuccessfully, to set my broken arm, using a tool which would have been familiar to the Spanish Inquisition. "Zhou are being very schtuborn, Americaner! Ve have _vays_ to make you talk!" That kind of scene. Of course, the subsequent operation was even worse. I don't think I really consented to the surgery. The chief surgeon decided up front what he wanted to do, and I was too spaced out on pain meds to dispute the point. The trolls seem to think that medical treatment is a consumer good. Europeans tend to spend less money on extreme treatment, probably because they are more realistic about what it will and will not do. Americans tend to give the doctor carte blanche, and then turn around and sue him for malpractice when their hopes are disappointed. Canadians are of course Europeans in the cultural sense.

bryan richard martin - 8/8/2007

Well put Max. I have been wanting to respond to some of the ridiculous arguments put forth by some the "socialized-medicine" scaremongers on this board. I have read some absolutely idiotic arguments here like the one questioning Quadango's numbers in regards to the number of uninsured claiming that she's wrong because she had not taken into account Christian Scientists??!! Another pathetic argument was put forth by someone claiming that when the government is responsible for your healthcare they will next try to modify your behaviour (read: less freedom). I don't know how many people have been to places like the UK (I have been many times)where they have nationalized healthcare but let me tell you, no one is telling them they can't have a few pints and some deep fried food for dinner, and many more folk over there smoke than here in the U.S. Cigarettes, alcohol, unhealthy deep fried foods are all still legal in that "totalitarian state" called the UK. I have not read a single, not one, compelling argument from you people against Quadango's claims.

Paul Noonan - 8/8/2007

I think the reason for "American Exceptionalism" on state provided health care is simply because so many Americans have employer funded health insurance. I believe that when most European countires adopted a state system most medical bills were paid out of pocket by patients as expenses were incurred (as was done in the US up to the 1940s).

I suppose the whole problem began when, during WW2, the government said that the wartime wage freeze then in effect was not violated if an employer added health insurance to its compensation package. This allowed employers to offer this benefit to attract scarce labor (what with 12 million in the armed services labor was scarce). This made employer funded health insurance common, previously it had been rare.

If, after the war, Harry Truman had faced an America where basically everyone still had to devastate their savings accouts to have their gall bladders removed (for example) likely he would have gotten his plan. But by then many had employer funded health insurance and others had a reasonable prospect of soon having a job with health benefits and he was defeated.

In the UK Churchill's government announced its intention in 1942 to institute what is now the NHS postwar. The Labour Party created the NHS between 1945 and 1948. The British Medical Association, like the AMA, was not enthusiastic, but they recognized the tide was against them and so devoted their energy to trying to get the NHS formed in a way that was least offensive to them rather than making a futile effort to stop it altoghter. The NHS was unstoppable because people in the UK still paid their own medical bills.

Mike F. Gordon - 8/8/2007

If 48 million Americans are without health insurance that means that 262 million do have some form of health insurance and many of those probably have better care available than would be provided by any national plan. So the conservative complaint that a single payer plan would mean less care available, regardless of its truth or not, has some resonance among those 262 million Americans.

Another consideration that anyone planning a single payer national plan needs to look at is immigration. I don't mean to turn this into an argument about immigration but without bringing the current situation under some kind of control any future national plan might also be providing health care for upwards of 12 million undocumented aliens.

So to answer your question. no not anytime soon.

Joseph Oliveri - 8/8/2007

How can we possibly expect this nation to adequately address its domestic needs when so much of our resources are being sent to Iraq? I believe I speak for millions of Americans who would support the premise that health care is possibly the most mportant domestic priority facing our nation. Yet we have a prsident who is in the pockets of pharmaceutical companies and a congress that despite the mandate of 2006 to get things done, is too concerned with further polarizing the nation than creating meaningful legislation that will ease our pain. So can health care reform be achieved? Yes, but first the conflict in Iraq has to wind down and monies spent there used for something that will restore faith in our government.

Max J. Skidmore - 8/8/2007

Jill Quadnago is one of the leading authorities in this country on health delivery and Social Security. She is an expert on the subject, and her expertise permeates her fine commentary on this country's system of delivering health care.

She should not have to defend herself against impassioned reactions from those who parrot the health industry's talking points, and who demonstrate their ignorance of the actual conditions. As could have been anticipated, though, her topic has brought lurid postings from those whose expertise consists of commenting on HNN articles.

Anyone who believes there is a "mass exodus" of patients from Canada who come here to seek health care simply knows nothing about the situation. What is the source of this "information?" Is it a radio talk show? How would Canadians pay for their care here? They don't have health insurance policies. It is true that waiting periods there are somewhat longer than they are here for some procedures--not, though, for emergency or life-endangering conditions.

Much of the difference involves joint replacement surgery. One tends to wait longer in Canada than in the US for, say, hip replacement. Note, though, that most such surgery is performed on elderly patients, and in the US this usually comes under Medicare--the government program--not under private insurance. Note also that there are often long waiting periods even in the US. Try, for example, to obtain an appointment with a dermatologist in most sections of the US and you will see what I mean.

Regarding the strange comment about government medicine driving up costs, just compare costs in the US with those anywhere else in the world. Literally everywhere else (including Canada) costs are far lower than here, and at least throughout the industrialized world (and in some poor contries as well) those lower costs come with universal coverage.

The US succeeds in paying far more for health care than other countries--ANY other country--while uniquely (in wealthy countries) leaving large numbers with no access to that health care. Moreover, the quality of that most expensive American care often is lower than that available in other countries. By nearly all objective measures, the US ranks far down the list in the quality of care it provides to its citizens--all the while paying more for that care than other countries do.

Is excellent care available here? To be sure--I have received it myself--but the general level of care available to the whole population falls far short of that in many other countries, and it is affected adversely by an inexcusable number of medical and hospital errors. This is clear from study after study.

As for hysterical comments about "government medicine" bringing "totalitarianism," compare a system in which every person has the care he or she needs, regardless, with ours in which one often either goes bankrupt from health-care costs, or finds that he or she cannot change jobs because it would involve a loss of health insurance. Additionally, how many people here think they are covered, only to find, when they need expensive care, that their insurance will not pay?

The Hoover-Hayek-etc. thesis that social welfare programs bring dictatorship is based on fear, not fact. There is no historical (as opposed to hysterical) evidence anywhere that this has ever happened. It isn't Social Security, Medicare, or even a national health service that has ever brought totalitarianism--anywhere. If it comes, it comes through programs based on the perceived need for suppression of civil liberties in the name of security or combatting crime.

In that regard, Americans should be more concerned with such things as the potential effects of the Patriot Act, the "drug war" and its asset forfeiture, and even with restrictions that come from protecting "intellectual property" than from government oppressing you by paying your hospital bills through Medicare, sending you a Social Security check, or someday, just maybe, making certain that you have the health care you need.

Mike Schoenberg - 8/8/2007

The fact that the VA can buy drugs at negotiated prices while Medicare-Medicaid have been outlawed from doing this is odd to say the least. Somehow in the US we now have a situation where we have police, fire departments etc. to protect us as well as our property but when it comes to health care and our bodies unless you work for the government like Dick Cheney or have insurance it'sd like Bush says-"Just visit the emergency room"

Jason Blake Keuter - 8/8/2007

it is true that in nations with socialized medicine, coverage is guaranteed for the cost of most medical care; the problem is that the medical care is in short supply and is frequently inadequate. patients are "covered" but must wait six months to a year to see a doctor and see them only once. Under socialism, good medical care is not only for the well-off; it is also for the corrupt, as bribes are necessary to get doctors with no financial incentives to provide good care to provide it.

absent from the health insurance discussion is any discussion of the role health insurance plays in inflating health care costs. The bulk of care costs come from a small minority of insured patients and the rest of the insurance payers pay for their freeloading with ever increasing premiums. The care insurance provides gives powerful incentives for high-priced specialists to cater to the deep-pocketed free-loaders. To guarantee coverage to everybody would thus increase, not minimize costs - unless rationing regimes hundreds of times more strict than those used by the evil HMO's were instituted.

Confronted with escalating costs, the government under a socialized system would be under pressure to regulate the lives of the covered so that they don't get expensive illnesses in the first place. Here we have the seeds of creeping totalitarianism - or at least bloated bureaucracies charged with supervising lives to assure they're not too sedentary to merit state subsidized gastric by-pass surgeries.

Hasn't the medicare viagra fiasco taught us anything?

Oscar Chamberlain - 8/7/2007

"Yet the public should demand that those who claim they have to capacity to lead the nation take a stand on an issue that is so critical to the well-being of every American family. "

Actually, it's not critical for every American family, at least not right now. A considerable number have pretty good health coverage. When any proposal comes up, a pretty natural question for them to ask is, Will this cost me more or will it weaken my current coverage.

Those were the fears that the health care industry played on so expertly when opposing Clinton's plan. The complexity of the plan made a good defense hard. If I remember currectly, so did Clinton's own unwillingness to state that the plan would cost more overall, at least in the short run.

I doubt if the political will is there for a single-payer plan. Incremental efforts are the way to go, despite the problems in knitting them together in a manner is cost effective.

Personally, I think a government funded catastrophic policy--something that keeps families from going broke when truly devestating illnesses hit--could be a major step forward. It could be purchased as a wrap-around by people with existing coverage, and it could be provided gratis to people below a certain income.

Rachelle Matherne - 8/7/2007

Just wanted to let you know I blogged about this article at the Health Care Reform Now! Book Blog:


Cleora G Leist - 8/7/2007

No one seems to mention the self-employed person who has trouble getting insurance they can afford. That had been my situation until Medicare age (private music teacher) and now that of my son. Because he is being treated for high pressure, it would cost his family of four $1,300 a month for insurance. They are doing without, even paying cash for foot surgery for his wife. However, he really doesn't appreciate being looked down upon because he has no insurance. Something else really needs to be done. The United States treats it's prisoners and war prisoners better than many in this country who are working. I do believe that getting the for-profit insurance companies out of the picture would help a lot. Even if you have insurance, there is no guarantee that it won't stop if you couldn't pay the premiums or the amount paid by them reached too high. My co-pays have doubled in the last year. If I wasn't still teaching, I couldn't pay for them. Everyone I know has horror stories to tell. Our politicians must find a solution. When we are #37 in the world in terms of amount spent for the value received, it's pretty sad.

George Robert Gaston - 8/7/2007

Last president to propose it to congress? Richard Nixon - Go figure.

Lawrence Brooks Hughes - 8/6/2007

Most people working in what is supposed to be the "non-profit" areas of medicine are making lots of money, too, while also getting free office space, company cars and long vacations, etc., to go with their excessive salaries. Those who report profits are not the only venal people in medicine by any means, nor probably even half of them.

John D. Beatty - 8/6/2007

This is a BUSINESS, people, an INDSUSTRY. It exists in very large part to make money.

Tell you what: lets apply this "system" reasoning elsewhere. Let's tell the automakers that they MUST provide cars for EVERYONE.

No? How about housing? Communications? Surely food? If the food system would only provide adequate nutrition for EVERYONE regardless of cost, all the world would be well.

Well, then, what? No part of the health care industry can make a profit until everyone is well? "Excess" profits are to be redirected to...where, now? And who decides what's "excess?"

Get real, people.

Mike Schoenberg - 8/6/2007

Come on, what stat's are you reading from when most that are reprted say that up to 70% of Americans are in favor of some type of reform. Those millions who may or may not be between jobs or just make close to minimum wage and therefore in your words"their net worth is too low"- these are the ones that Bush says can just go to an emergency room and then taxpayers have to pay for it. What % of Canadians are crossing the border for better and faster care. Doesn't seem like I here that one can get an appointment in a day here.

Lawrence Brooks Hughes - 8/5/2007

Ms. Quadagno has glibly outlined the health care situation in the U.S. --as she sees it. She doesn't tell you about all the mess in foreign countries with universal government care, the long waits for surgery, the assignment of doctors you don't like, the mass exodus to America from Canada by people who are really sick, the mass exodus of doctors to America from all over the world, etc. You have a dual system in Great Britain of goverment health care for the have-nots, and expensive health care for the affluent, in two systems side by side. She doesn't point out that millions of Americans get fully-paid health care insurance from their employers, while millions of others must buy their own with after-tax dollars, thanks to the privileges offered to government workers and certain others, while denied to millions by our unfair tax laws. She doesn't mention that millions who are uncovered at any given time--and who show up in her statistic of the total uncovered-- just happen to be temporarily between jobs. She doesn't mention that millions who are uncovered do not find it smart to buy health insurance because their net worth is too low to justify the cost of such protection. A great many young people simply don't feel it is worth it, especially since they never get sick. We also have Christian Scientists, and other who do not believe in medicine. Are we going to coerce them, or let them remain free in what used to be a free country? Perhaps worst of all, she never mentions what universal government-paid care does to send medical costs into upward spirals... She doesn't report that most surveys show most people are rather happy with the present system in the U.S. ... No new system should be adopted which does not include incentives for cost containment, such as co-pays, and choice, including the choice of taking your money home instead of feeding some customer-unfriendly medical bureaucracy.