Is History Relevant to Implementing Health Reform?

Daniel M. Fox; Howard Markel

JAMA. 2010;303(17):1749-1750 (doi:10.1001/jama.2010.556)
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 COMMENTARY
Is History Relevant to Implementing
Health Reform?
Daniel M. Fox, PhD
Howard Markel, MD, PhD
O
N M ARCH 5, 2009, FROM A BULLY PULPIT IN
the East Room of the White House, President
Barack Obama opened a health care confer-
ence with a historical parable. “Since Teddy
Roosevelt first called for reform nearly a century ago,”
the president said, “we have talked and we have tinkered.
We have tried and fallen short, we’ve stalled for time, and
again we have failed to act because of Washington poli-
tics or industry lobbying.”1
A year later, on March 8, 2010, while stumping for the
health care bill that he ultimately signed into law on
March 22, President Obama again invoked his predeces-
sor by noting, “Think about it. We’ve been talking about
healthcare for nearly a century. I’m reading a biography
of Teddy Roosevelt right now. He was talking about it.
Teddy Roosevelt.”2
The president is correct that reformers have promoted
measures to secure Americans against disease, disability,
and want since the first decade of the 20th century. His
implication that incremental solutions have always fallen
short of universal coverage for health care is also correct.
Nevertheless, reformers and presidents of past eras did
more than talk about health reform. They overcame con-
siderable resistance to enact and implement it, beginning
with the old age and survivors insurance created by the
Social Security Act of 1935.3 What is now simply called
Social Security enabled retirees to purchase health care at
a time when it was considerably less expensive because
physicians had much less to offer their patients than they
do now.
Subsequent increments of reform helped Americans
pay for health care as it became increasingly beneficial
and expensive. The Eisenhower administration expanded
Social Security in 1956 to provide income for persons
with disabilities. A decade later, Lyndon Johnson signed
Medicare and Medicaid into law to cover health care and
long-term care for retirees and the poor. In 1972, during
the Nixon administration, Congress passed legislation
extending Medicare to persons of any age who were eli-
gible for Social Security Disability Insurance. In 1997,
three years after the Clinton administration’s failed health
©2010 American Medical Association. All rights reserved.
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care bill, the State Children’s Health Insurance Program
was enacted, extending coverage for millions of children
in families with employed adults and low incomes. Since
2004, Medicare has covered prescription drugs—a pro-
gram first endorsed by President Reagan.4
When President Obama cited Theodore Roosevelt but ig-
nored subsequent health care reform events, he was using
history as an analogy or moral tale to justify passage of a
controversial bill. But history can also offer guidance about
the implementation of legislation that, like health reform
in 2010, had bitter antagonists as well as enthusiastic sup-
porters and required complicated rules for eligibility and fi-
nancing.
In his campaign for president in 1912, Theodore Roosevelt
vaguely called for the “protection of home life against the
hazards of sickness . . . and old age through the adoption
of a system of social insurance.”5 His successors learned how
difficult it was to achieve even a portion of this noble goal
in a diverse, fragmented society, which, despite national ide-
als, has always been characterized by conflicts about ideol-
ogy, economic and professional interests, and regional val-
ues. Moreover, presidents in the decades since had to
implement legislation that had flaws and gaps as a result of
negotiations with members of Congress and lobbyists. With
the exception of catastrophic coverage in 1989, they suc-
ceeded, against strong opposition, in expanding and insti-
tutionalizing Americans’ safety net, while always, as in 2010,
falling short of universal coverage.
Historians have too much respect for contingency to dare
predict the future. Still, as the nation embarks on the long
road of implementing the 2010 health reforms, historical
research can be used to construct a checklist for measuring
continuity and discontinuity with past attempts.
Antagonism to reform in the months, even years,
after it is enacted is often fierce and vitriolic; but it has
a half-life. Opponents of “old age” insurance under Social
Security insisted after its enactment that the program
would increase unemployment and was unsound finan-
cially. They took political advantage of the almost 5 years
between enactment in 1935 and the payment of the first
Author Affiliations: Milbank Memorial Fund, New York, New York (Dr Fox); and
Center for the History of Medicine, University of Michigan Medical School, Ann
Arbor (Dr Markel).
Corresponding Author: Howard Markel, MD, PhD, Center for the History of Medi-
cine, University of Michigan Medical School, 100 Simpson Institute, Box 0725,
102 Observatory, Ann Arbor, MI 48109-0725 (howard@umich.edu).
(Reprinted) JAMA, May 5, 2010—Vol 303, No. 17 1749
COMMENTARY
monthly benefits. For months after Medicare’s enact-
ment, members of the American Medical Association
threatened to boycott the program, 4(pp198-201) despite
persuasion—eventually successful—by the association’s
leaders to abandon this extreme position. In 1989, orga-
nizations speaking for affluent beneficiaries who opposed
Medicare Catastrophic Coverage persuaded Congress to
repeal the program. But just as Social Security old-age
and disability insurance and Medicare gradually gained
widespread, bipartisan acceptance, Congress enacted a
drug benefit for Medicare beneficiaries 15 years after it
was included in legislation creating the Medicare Cata-
strophic Coverage program and then repealed.
Symbolic politics matters. Franklin D. Roosevelt said that
payroll taxes were about politics, not economics. “We put
those [contributions] there so as to give the contributors a
legal, moral and political right to collect their pensions.”6,7
Roosevelt emphasized insurance and worker ownership in
explaining the delay between enactment and delivery of ben-
efits; funds had to accumulate in the trust fund. In 1965,
Lyndon Johnson, to symbolize continuity, went to Mis-
souri to sign the bill creating Medicare and Medicaid in the
presence of Harry Truman, who had advocated sweeping
health reforms in 1948.
Neither the Left nor the Right can be placated but nei-
ther has anyplace else to go. Liberal New Dealers criti-
cized the Social Security Act for its gaps in coverage and
discrimination against African Americans. They com-
plained that disability coverage under Social Security
excluded persons with partial or temporary disability.
Their successors were frustrated when Medicare did not
lead directly to universal coverage; and another generation
complained when Part D prohibited the federal govern-
ment from negotiating prices of pharmaceutical drugs.
Similarly, Alf Landon, the Republican candidate for presi-
dent in 1936, ran against Social Security; so did Barry
Goldwater in 1964, despite Eisenhower’s support for the
program. When Medicare and Medicaid did not have the
deleterious effects advocate Ronald Reagan had predicted,
the Republican right began to demand market-based solu-
tions to contain the cost of these programs. To the conster-
nation of many of them, Reagan administration reforms of
Medicare tightened public management and introduced
the effectiveness of health care as an issue.
Interest groups’ perception of self-interest can change.
Although many business leaders opposed Social Security at
its inception, most embraced it by the end of World War II
1750 JAMA, May 5, 2010—Vol 303, No. 17 (Reprinted)
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as an essential complement to private pensions and a source
of workforce stability. Many physicians, who wanted to boy-
cott Medicare in 1965, soon became accustomed to its fi-
nancial benefits. By 2004, government payers accounted for
32.7% of total physician income; 4 specialties (including both
the lowest and the highest paid) received more than 50%
of their outpatient income from public sources.8
The plural of anecdote is policy. Most politicians value
anecdotes over resonant political rhetoric because each an-
ecdote, especially about health care, involves a voter and
members of his or her family. Moreover, each anecdote about
someone who benefits from a new or expanded entitle-
ment undercuts the rhetoric of enemies of reform.9
The politics of implementing reform is difficult to in-
terpret because it is practiced at many levels. These poli-
tics are simultaneously local, statewide, regional, and na-
tional. The politics of implementation is, moreover, always
influenced by interest and advocacy groups and shadowed
by issues of race, ethnicity, gender, and religious beliefs. Poli-
ticians, across the political spectrum, have been trained to
assess this complexity—and how it changes—and to im-
provise tactics to address it. With the temporary exception
of Medicare Catastrophic Coverage, policy makers who led
in enacting major entitlement reform have managed to imple-
ment it. Indeed, history teaches that the real work of health
reform is just beginning.
Financial Disclosures: None reported.
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©2010 American Medical Association. All rights reserved.