Will We Ever Get National Health Insurance?
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.