The More Things Change

February 22, 2010

The fact that presidents have been trying to get some form of universal, government supported health insurance for almost 100 years now has been well publicized. What is less known is why — with the exception of the passage of Medicare and Medicaid in 1965 — almost all of their efforts have failed to produce substantive change. It’s instructive to look back in some detail to better understand the issues involved and what went wrong in each case. Such an exercise is essential to understanding both the forces that continue to shape public policy in America and the tactics that can affect those forces.

A review of history and even our current situation tells us that that the issues really haven’t been about whether or not Americans want some form of government help with the costs of medical care. In polling data going back to the 1930s, Americans have almost always responded favorably to the idea of the government playing a role in providing financial support for health care. For example, in a 1937 Gallup poll (cited by Hazel Erskine in 1975), 73 percent of respondents said “yes” when asked if the federal government should provide free medical care for those unable to pay. Even today, despite the debate and negative feelings around the proposals that passed the Senate and the House at the end of 2009, 63 percent of Americans still say they want Congress to pass comprehensive health care reform. So, the problem is less about whether or not people want health care reform than it is what “reform” really means to them, and also, fear of change.

From 1912 to 1916, the Progressives thought that they had strong support for government funding of health care and believed it would be easier to get “social insurance” than it was to get workers’ compensation or other such initiatives. In 1931, I.M. Rubinow wrote a fascinating article about the failure of health reform in 1916. Rubinow’s analysis provides a vivid picture of interest group politics and American values. Who knew, for example, that the inclusion of a funeral benefit in the proposed social insurance would be, as Rubinow puts it, “a grave tactical error because of its implied threat to the gigantic structure of industrial life insurance…”? Or, that there would be an unexpected attack from “Christian Scientists and all other medical cults… who saw a sinister effort of conventional medicine to suppress religious and medical freedom.”

Rubinow explains how, in the face of the attacks from the different interest groups, Americans began to reflect more on their individual rather than communal priorities with the “young and healthy and unmarried” not wanting to take on the burden of those who were “older and the sickly.” The interest group politics of the early 1900s and the anti-health reform lobbying it spawned led the population at large to fear the loss of the status quo — even if the status quo wasn’t so great. As Rubinow says, the proposal was condemned in part because “it would interfere with the natural right of the poor workman to select his own medical adviser, the right they now exercise to a large extent by waiting in line many hours for admission to a free clinic.”

Rubinow drew many lessons from the failed effort to achieve social insurance by the Progressives in 1916. His catalog of what went wrong is eerily prescient of what went wrong in later eras — including what has happened so far in our own. Just substitute some of the details of the time and the names of current interest groups and the same basic issues are evident. I particularly like this part of Rubinow’s conclusions: “Concerted opposition is very much more stubborn than concerted advocacy of the measure, and not only stubborn, but blind…. Occasionally farsighted individuals see [the benefit of the measure]. The organized group seldom does.”

Sound familiar?


The Polls: Health Insurance
Author(s): Hazel Erskine
Source: The Public Opinion Quarterly, Vol. 39, No. 1 (Spring, 1975), pp. 128–143, page 130
Publisher(s): Oxford University Press on behalf of the American Association for Public Opinion Research
Stable URL: (subscription required to view the full text)

Conflict of Public and Private Interests in the Field of Social Insurance
Author(s): I. M. Rubinow
Source: Annals of the American Academy of Political and Social Science, Vol. 154, The Insecurity of Industry (Mar., 1931), pp. 108-116
Publisher(s): Sage Publications, Inc. in association with the American Academy of Political and Social Science
Stable URL: (subscription required to view the full text)