Lesson? U.S. history shows few major health laws ever enacted
Above the hyper-politics, traditional American skepticism about health ‘reform’
If history can shine one ray of light through the cloud of unknowing surrounding the debate about our health care system, it may be this: In 230 years, there have been only two landmark legislation acts that fundamentally changed the structure of health care delivery in America. Even important but narrower legislation is rare when it comes to how we procure and pay for our doctors, hospitals and medicines.
This might provide a bit of useful and perhaps calming perspective on today’s tempest.
History hints that the campaign to replace Obamacare with Trumpcare faces longer odds than we might otherwise think and not just for the current Republican proposal but for the whole repeal project.
Ferocious, partisan arguments polluted with demagoguery, fictional statistics and tribal economic theories about health care reform break out frequently in our history. Sweeping new laws, however, come far less frequently than Halley’s Comet.
Is a comet coming? History lessons aren’t quite that precise and predictive. But there are no indications that Americans have abandoned their traditional skepticism about their elected representatives’ ability to make things better.
As the prospect of replacing Obama with Trumpcare moves from campaign bombast to legislation, Americans are growing more concerned about big change.
A poll released at the end of February by the studious Kaiser Family Foundation found that more people (48 per cent) approved of the Affordable Care Act, aka Obamacare, than disapproved (42 percent). That is the highest approval rating for the law in a Kaiser poll since 2010. Moreover, 56 per cent say they are “worried” about plans to “repeal” Obamacare. A more recent Kaiser poll shows large pluralities believe the GOP/Trump proposal would result in fewer people with insurance and increased overall costs for most everyone who buys their own insurance.
It is possible that politicians and voters have found themselves on a crusade with no idea of what the Holy Grail actually is anymore.
What is the urgent Public Health Enemy # 1 that repealing Obamacare would solve? There is nothing close to a national consensus on that, not even a Republican one. Some blame Obamacare for every problem in their medical life. But exactly how would Trumpcare fix that and reliably do better?
There is a trail of circumstantial evidence starting around 1912 that suggests in the absence of palpable agreement that there is an urgent problem and a potential solution, radical reform dies. Teddy Roosevelt ran as the nominee of the Progressive Party that year on a platform that had a first — a call for health insurance for the workers of the Industrial Age. They lost.
Franklin Roosevelt tried to include health insurance in the first round of New Deal programs. He lost — and lost again later in his long tenure.
The end of World War II offered an opportunity. Harry Truman was a full-throated booster of universal health insurance. Some opponents, gripped by Cold War fever, called it socialism. (They still do.) Southern Democrats feared it could desegregate hospitals. Truman failed.
By the 1960s there was a clear and present danger and it affected almost everyone. Health care had become much more expensive. Old and retired people couldn’t afford it and couldn’t get health insurance. Their children couldn’t afford to pay their parents’ bills. John F. Kennedy pushed a program to address that. He failed.
The problem got worse. On July 30, 1965, Lyndon B. Johnson signed the bill that created Medicare and Medicaid with Harry Truman at his side. It was the first landmark, America’s first law establishing broad government-based health insurance.
In the 80s a severe problem plagued a group of voters with clout — seniors. Hospital bills and prescription medicines were becoming unaffordable. They made themselves heard. In 1988, Reagan signed major legislation intended to better cover prescriptions and medical catastrophes. The new benefits were funded by new Medicare premiums. When time came to pay the premiums, however, seniors revolted. The Reagan bill was repealed in 1989.
Then came the Health Security Act — HillaryCare. There was wide agreement on the problems: rising uninsured, out of control costs and health care was devouring too big a slice of the economy. But no agreement on the solution. The Clintons failed.
Barack Obama faced a dire problem: More than 15 per cent of Americans lacked health insurance, 45.6 million people. It was a crisis of decency and economics: Sick and injured people who didn’t have coverage still received care at hospitals. Hospitals and doctors were stuck with bills they had no way to pay. Some costs were passed on to people with insurance.
Obama pushed reform in 2009 with substantial business support and episodic Republican cooperation. The Patient Protection and Affordable Care Act passed the House and Senate in 2010, with no Republican votes. It was only the second comprehensive health care law in American history.
There is no doubt that America today faces severe, fast growing health challenges such as obesity, diabetes and opioid addiction. There also is no doubt the ACA needs repair, that the health care “system” is inefficient and underperforming compared with other wealthy countries.
History suggests, however, that there is considerable doubt that Americans are prepared to accept any solutions Congress and the president might come up with.
Today’s debate comes at a period of rancid partisanship and the lowest levels of trust in government ever recorded. The times seem sour, not ripe, for major reform. But Donald Trump, so far, has defied history and the old rules of politics and presidential tradition. Fools predict where historians fear to tread.