Health Reform: What a Long Strange Trip it’s Been – Part 1

Implementation of health reform poses formidable challenges for Democrats, Republicans, and the political process itself. What can the past teach us about what to do now?


“What is old is new again”


Today’s health reform debate is deeply rooted in the ideologies and legislative efforts of the past 75 years.

Should Social and Environmental Determinants of Health be part of reform efforts? In 1945, President Harry Truman proposed solutions to these issues as part of comprehensive health reform. Can we legislate “healthcare for all” while maintaining a private system that allows consumers to choose their own physicians? In 1962, President John F. Kennedy championed such an approach.

Sound like familiar issues relevant to today?

Understanding past struggles helps to shape our current efforts for positive change by providing useful perspectives on the similarities of issues as well as the politics of reform that have persisted for decades.

And so, here’s a short history on the “roots” of today’s issues and efforts to improve health systems in America.

This installment (Part 1) begins in the 1940’s and culminates in 1969 with the landmark passage of both Medicare and Medicaid.

In Part 2, we’ll look at reform efforts from the 1970’s leading up to the passage of the Affordable Care Act and what’s happening today.


1933-1945: Franklin D. Roosevelt Administration

While health reform as a movement in the United States goes back to the early 1900’s, a national effort supported by a significant political party emerged in the 1940’s. President Franklin Delano Roosevelt believed in the concept of “healthcare for all” as part of his broader view on the role of government to create and manage “social programs” to benefit all Americans.

His key push to provide Healthcare for All was part of what would become known as “America’s Second Bill of Rights.”

President Roosevelt taking his case for Universal Health Coverage to the people as part of his initiative known as America’s Second Bill of Rights.

As World War II was coming to a close, it had been rumored that Universal Health Care was to be President Roosevelt’s next big political crusade. Unfortunately, he died just before the end of the war and so the world would never really know what might of come from President Roosevelt’s resolve to make healthcare accessible to all.


1945-1953: The Truman Administration

In November of 1945 President Harry Truman called on Congress with a special message recommending passage of a Comprehensive Health Program.

President Harry S. Truman

You can access the full speech here which enumerates the vision, issues and opportunities to deliver universal coverage to all Americans.

While the full speech is worth reading, there are two areas that are especially relevant to the challenges of today.

The first area of importance is where the Truman administration puts forward the tenent of healthcare as a “right”:

“In my message to the Congress of September 6, 1945, there were enumerated in a proposed Economic Bill of Rights certain rights which ought to be assured to every American citizen. One of them was: “The right to adequate medical care and the opportunity to achieve and enjoy good health.” Another was the “right to adequate protection from the economic fears of sickness.”

Millions of our citizens do not now have a full measure of opportunity to achieve and enjoy good health. Millions do not now have protection or security against the economic effects of sickness. The time has arrived for action to help them attain that opportunity and that protection.”

Harry S. Truman in a speech to Congress advocating healthcare as a right.

The second area that is especially noteworthy to today’s challenges and struggle for comprehensive reform is this: Long before contemporary experts began championing the notion of Social and Environmental Determinants of Health, Harry Truman nailed the correlation of these factors to the health of a nation. His proposal tied social and environmental issues to the macro view of what “systems of health” should include:

” If we agree that the national health must be improved, our cities, towns and farming communities must be made healthful places in which to live through provision of safe water systems, sewage disposal plants and sanitary facilities. Our streams and rivers must be safeguarded against pollution. In addition to building a sanitary environment for ourselves and for our children, we must provide those services which prevent disease and promote health.”

Harry S. Truman advocating that Social and Environmental Determinants of health be part of a national health plan.

The issue that ultimately became the lightning rod for Turman’s proposal was a provision that called for universal health insurance coverage to be administered and paid for by a National Health Insurance Board. The American Medical Association, quickly decried this to be “socialized medicine,” with a Congressional subcommittee labeling the approach “communistic.” The bill died, but Truman continued pushing for expanded access to health services right up to the outbreak of the Korean War which then took priority.


1953-1961: The Eisenhower Administration

President Dwight Eisenhower was known from his military career as a brillant strategist who then became an effective and savy politician.

In reviewing the impact of Truman’s push for health reform, Eisenhower came forward with a more modest approach and a very clear message for Congress, voters and special interest groups to hear:

“I am flatly opposed to the socialization of medicine. The great need for hospital and medical services can best be met by the initiative of private plans. But it is unfortunately a fact that medical costs are rising and already impose severe hardships on many families. The Federal Government can do many helpful things and still carefully avoid the socialization of medicine.”

President Dwight Eisenhower
National television broadcast to promote Eisenhower proposal for national health reform.

President Eisenhower proposed a four-part plan to increase access to affordable care for more Americans that included:

  • Federal funding to increase number of hospitals in the United States.
  • Legislation and funding increase services to those with “disabilities.”
  • Greater flexibility in allowing states to utilize federal funds for public health services.
  • Private health insurance reform to encourage new types of plans to cover more Americans.

To pitch this plan to the American public, and make very clear the differences compared to the proposals made by the Truman Administration, President Eisenhower made use of the new political tool of television (social media of the 1950’s) to make his case for health reform.

Sidenote: While the clip above is worth watching for the sake of understanding what was being proposed, it is most noteworthy in that the majority of the broadcast features one of America’s first female cabinet members Oveta Culp Hobby.

Like so many woman leaders whose contributions are lost in history, Hobby was first female secretary, of the new Department of Health, Education, and Welfare. In this role, she made the (then controversial) decision to approve Jonas Salk‘s polio vaccine. She was also the first women to receive the Army’s Distinguished Service Medal for her leadership efforts during WWII, including serving as the head of the Women’s Army Corps which was created to fill the gaps left by a shortage of men. The brilliance and contributions of Oveta Culp Hobby comes through in this short clip.


1961-1963: The Kennedy Administration

Under President John F. Kennedy, a proposal for expanding access to health services included health insurance coverage for those 65 years and older as part of a Social Security benefits package.

While this work began laying a foundation for what would ultimately become Medicare, it was met with strong opposition by special interest groups. Frustrated by the efforts of special interests to kill a bill making its way through Congress, President Kennedy went on the road to make the case for his proposal directly to the public in a series of public rallies. This effort culminated in the spring of 1962 with a rally in New York City.

Madison Square Garden: President Kennedy making the case for expanding access to health care.

Eighteen thousand citizens packed Madison Square Garden with Kennedy’s speech being televised nationally. Despite public opinion being in favor of Kennedy’s proposal the bill was defeated in Committee. President Kennedy vowed to press forward but did not live to see his plan come to fruition.


1963-1969: The Johnson Administration

Following the death of President Kennedy, Lyndon B. Johnson (LBJ) was sworn in as the President of the United States. He then won a landslide victory to be elected to a full term as President in November, 1964.

President Johnson was purposeful in visibly picking up the social programs that President Kennedy had proposed in order to “keep a promise made to the American Public.” With a Democratic majority in both houses of Congress, President Johnson had a receptive body for extensive social reforms that came to be known as the Great Society.

Even with control of Congress, there was strong opposition from the American Medical Association, conservative Republicans and congressional leaders within his own party.

With President Johnson working behind the scenes to build a coalition to support both Medicare and Medicaid programs, the Social Security Amendment was introduced in the House Ways and Means Committee in March of 1965, gained final approval by the Senate on July 28, 1965 and was signed into law by President Johnson on July 30, 1965.  It is noteworthy that such landmark legislation was passed within the first six months of President Johnson taking office.

“No longer will older Americans be denied the healing miracle of modern medicine. No longer will illness crush and destroy the savings that they have so carefully put away over a lifetime.

President Johnson on the signing of Medicare into law

As originally enacted, healthcare coverage would now be provided to those 65 years of age and older, and to the poor, blind and disabled. It covered healthcare services provided by hospitals, physicians, nursing facilities and home care providers. 

A behind-the-scenes look at what it took to make Medicare a reality.

Medicare was milestone legislation that guaranteed healthcare as a right for seniors. It showed that major reform is possible with the support of the public, and the alignment of the powers in Washington.

It should also be noted that such progress was made because elected leaders made healthcare access a legislative and executive priority. Even then, reform was a hard-fought battle.

The clip above from CBS’ Washington Unplugged is an exceptionally candid behind-the-scenes look at what President Johnson went through to make Medicare a reality. It demonstrates the kind of resolve and types of action needed today to enact meaningful reform going forward.

In Part 2, we will look at health reform events in the 1970’s leading up to the passage of the Affordable Care Act in 2010.

All videos used in this story provided via links to original content on YouTube. Full attribution and copyrights property of the original content owner who post to YouTube.

The Single Most Important Question in the Reform Debate

Regardless of your political leanings your approach to any reform proposal will be anchored to this single question.

Regardless of your political views or social priorities, your approach to any health reform proposal or debate should be anchored to a single question. Directly or indirectly, how you answer this question is central to evaluating any proposal for creating sustainable reform.

The question that is foundational to all others in the health reform debate comes down to this:

Is healthcare a right or a privilege?

For the record, while most other developed countries have constitutionally declared or legislated healthcare as a right for all citizens, America has not. This is not an editorial comment but a statement of fact.

When the framers of the Constitution and Bill of Rights were defining fundamental human rights, average life expectancy was 35 years of age. [i]  The concept of “healthcare” as we know it today simply did not exist.

Healthcare as a right means that all citizens are guaranteed access to some level of care or services. While the type or level of service might change, the commitment of equal access to “something” does not.

For example, Canada decreed healthcare as a right in 1984.  Their system is known for guaranteeing all citizens access to certain services but often then keep patients waiting in line to access services based on budgetary targets. The United Kingdom guarantees all citizens the right to care with a founding principle of “free at the point of service” but often have some people waiting in line for service while others buy supplemental insurance policies that allow them to “jump the que” and gain better access to services.

Regardless of how the system is organized, or how well it actually works, healthcare as a right means that there is a safety net that catches all citizens.

The debate about healthcare as a right in America began with the advent of two events in history.

The first was the beginning of the Industrial Revolution. A massive shift of people going from working on farms to factories gave rise to a new set of health issues and began the debate on the role of private companies and the government in providing for the health of workers and citizens.

Around the same time medicine moved out of the shadows of quackery and into the realm of being a repeatable, scientific discipline.

Ever since, America has wrestled with whether healthcare is a right or privilege.

In the 1940’s President Roosevelt attempted to address the issue of whether healthcare is a right as part of a broader social initiative known as America’s “Second Bill of Rights.”

As WWII was coming to a close, FDR put forward a sweeping social program known as America’s Second Bill of Rights that included healthcare.

In 1945 President Truman proposed a national health program to include all Americans declaring in a speech to Congress “We should resolve now that the health of this Nation is a national concern; that financial barriers in the way of attaining health shall be removed; that the health of all its citizens deserves the help of all the Nation.”  It was denounced by the American Medical Association and called a communist plot by a House subcommittee.[ii]

The Clinton administration made healthcare their top platform priority but failed to get a plan through Congress.

Finally, the Affordable Care Act was passed during the Obama administration (aka Obamacare) in 2010 that created vehicles for citizens to have access to health plans while mandating coverage and fines for those choosing not to participate. The Trump administration from the outset worked to disassemble the Affordable Care Act.

The brief history of Affordable Care Act noted above is a cautionary tale that shows us that until healthcare is deemed a right, the fate of lasting reform will rise and fall based on the whims and views of those who control Congress and the White House (This situation continues to play out as I write this article).

An interesting corollary to the right to healthcare is our view and laws pertaining to the “right” to education. While the U.S. Constitution does not explicitly enumerate a positive fundamental right to education, a series of court decisions and legislation provide any citizen a right to a certain level of education.

As daunting as it may seem, American voters, business and political leaders have shown that they can commit to healthcare as a right in certain circumstances.

Healthcare has been decreed as a right in certain situations and for certain people. As part of the Great Society, congress enacted legislation in 1965 to guarantee seniors the right to healthcare via the Medicare program and to assist states in the provision of health services to the indigent via Medcaid.

And, since 1986, all citizens have a right to assistance in an emergency room…Unfortunately, the law only requires that a patient be stabilized. [iii]  After that you are subject to the whims of the situation.

If you believe that healthcare is a right, then any proposal for reform must call out and explicitly address this issue.


For Consideration:

  • Do you believe healthcare to be a right or a privilege?
  • If you believe healthcare to be a right, the question that follows is “a right to what?”  Is there a set of services to which everyone has access?
  • How should any proposal for reform address these fundamental questions?

Additional Resources

To better understand the history of this issue in the United States, see the article , Health Reform – What a Long Strange Trip It’s Been.

Learn which countries have Universal Health Access and explore how each has achieved this status (single payer, private system mandates, other models) from Wikipedia.

References:

[i] http://keywen.com/en/LIFE_EXPECTANCY

[ii] Dr. Howard Markel, “69 years ago, a president pitches his idea for national health care”. November 19, 2014. PBS Newshour. http://www.pbs.org/newshour/updates/november-19-1945-harry-truman-calls-national-health-insurance-program/

[iii] Health Care for Some: Rights and Rationing in the United States since 1930. Beatrix Hoffman.  University of Chicago Press. 2012

Health Costs and the Disappearing Paycheck

Annual health deductibles for workers have increased eight times faster than wages in the past decade. How is this impacting families?

Every day in America the discussion of Health Costs goes from the news room to the living room of 152 million Americans whose benefits provided by an employer sponsored plan. They don’t need the news anchor to tell them things are going in the wrong direction.

The latest Health Benefits Survey by the Kaiser Family Foundation tells the story of how healthcare costs are increasingly eating up more of the earnings of workers particpating in plans that are becoming harder for companies to provide as costs escalate.

The  2018 benchmark Kaiser Family Foundation Employer Health Benefits Survey chronicles the impact of rising health costs on both workers and employers of all sizes providing sponsored health plans. Top line things to know from this survey:

  • Annual family premiums for employer-sponsored health insurance rose 5 percent to average $19,616 in the past year, extending a seven-year run of moderate increases. On average, workers are now contributing $5,547 toward the cost of family coverage, with employers paying the rest.
  • Since 2008, annual deductibles have increased eight times faster than workers’ earnings and three times faster than general inflation.
  • A quarter (26%) of all covered workers are now in plans with a deductible of at least $2,000, up from 22 percent last year and 15 percent five years ago.  Among covered workers at small firms (fewer than 200 workers), 42 percent face a deductible of at least $2,000.

While there is a great deal of focus on expanding access to health services for the uninsured, those who are insured by company plans face their own set of challenges in the ever-growing personal costs of being insured.

The burden of deductibles on workers will continue to impact them in two ways: a growing share of covered workers will face a general annual deductible, and the average deductible will continue to increase faster than increases in take-home pay.

When it comes to employers being proactive in finding ways to help employees manage health (rather than merely paying bills when they are not) there are several trends worth noting:

  • Among large firms that offer health benefits, one in five (21%) report they collect some information from workers’ mobile apps or wearable devices such as a FitBit or Apple Watch as part of their wellness or health promotion programs. That’s up from 14 percent last year.
  • Most large offering employers (70%) provide workers with opportunities to complete health risk assessments, which are questionnaires about enrollees’ medical history, health status, and lifestyle, or biometric screenings, which are health examinations conducted by a medical professional, or both. Thirty-eight percent of large offering firms provide incentives for workers to participate in these programs. The maximum financial incentives for these and other wellness programs often total $500 or more.
  • Telemedicine: About three quarters (74%) of large offering firms (at least 200 workers) cover services provided through telemedicine, such as video chat and remote monitoring, which allow a patient to get care from a provider at a remote location. That’s up from 63 percent last year and 27% in 2015.
  • Retail health clinics: Similarly, three quarters (76%) of large offering firms cover services received in retail clinics, such as those located in pharmacies, supermarkets and other retail stores. A small share also provide financial incentives for workers to use these clinics.

“Health costs don’t rise in a vacuum. As long as out-of-pocket costs for deductibles, drugs, surprise bills and more continue to outpace wage growth, people will be frustrated by their medical bills and see health costs as huge pocketbook and political issues,” KFF President and CEO Drew Altman said.


For Consideration:

  • How is the trend of rising deductibles and other “out-of-pocket” expenses impacting you and your family? Is this a minor inconvenience or a major issue impacting other aspects of your life (e.g. daily living expenses, vacations, saving for retirement or college)?
  • How does this issue rank relative to issues you would like to have elected leaders review and address?
  • To lower costs how open are you to trying new activities such as actively particpating in workplace wellness programs or using lower cost care options such as telemedicine?

Additional Resources:

The complete Employer Health Benefits Survey report can be downloaded here which includes over 200 exhibits and in-depth review of key issues impacting both the worker and the employers who also continue to be impacted by rapidly increasing health costs.

Download the Summary of Findings which provides an overview of the 2018 survey results. This serves as a great handout for discussions or email attachment for those interested in learning more about this important issues impacting workers.

This related brief on the Peterson-Kaiser Health System Tracker examines employer claims data to measure the uptake of telemedicine services by employees and their family members.

Financial Burden of Medical Care: A Family Perspective: This downloadable data brief from the National Center for Health Statistics utilizes data from the National Health Interview Survey (NHIS) to provide key findings on the financial burden medical care has on American families. The brief reports that 1 in 5 persons was in a family having problems paying medical bills, and 1 in 10 persons was in a family with medical bills that they were unable to pay at all.


Does Sugar Addiction Impact $1 Trillion in U.S. Healthcare Spending?

This article looks at the explosion of added sugars in our food and drink supply and reports on the health and cost consequences to all.

It is clear that the obesity epidemic is a key issue in the health reform debate as research conclusively shows that it drives significant increases in chronic diseases like coronary heart disease and diabetes.

What is less clear from a science and public policy perspective is the role sugar plays in both obesity and chronic diseases and what, if anything, should be done to regulate or manage its presence in our food and drink supply as part of the health reform debate in the United States.

“Sugar: Consumption at A Crossroads” is a groundbreaking report from the Credit Suisse Research Institute that explores the medical, economic, consumer and public policy implications of global sugar consumption.

Amongst the many data points and in-depth content in the report is this estimate of the economic impact of sugar in the United States:

“30% – 40% of healthcare expenditures in the USA go to help address issues that are closely tied to the excess consumption of sugar.”

The consumption of added sugar (sugar not contained in natural products like fruit or milk) or high-fructose corn syrup (HFCS) has increased dramatically over the last few decades. According to this report:

  • The world daily average consumption of sugar and HFCS per person now averages 17 teaspoons per day, up 46% from 30 years ago. This is the equivalent of 280 calories per day.
  • In comparison, Americans now consume an average of 40 teaspoons per day. As a benchmark, the American Heart Association recommendation for daily sugar intake is six teaspoons for women and nine for men.
  • Added sugars now represent 17% of a normal US diet with 43% of added sugars coming from sweetened beverages.

The report also includes a survey of physicians in the US, Europe and Asia. Key points from the physician view include:

  • 90 percent of the doctors surveyed believe that the sharp growth in type II diabetes and the current obesity epidemic are strongly linked to excess sugar consumption.
  • 82% of the doctors surveyed in the U.S. and Europe believe that sugar calories are handled differently by the body. 
  • On the question “is sugar addictive,” 65% think this is the case.

While medical research has yet to prove conclusively that sugar is the leading cause of obesity, diabetes type II and metabolic syndrome, the balance of recent medical research studies are coalescing around this conclusion. Advances in understanding the negative effects of refined carbohydrates on blood sugar regulation and cholesterol, and the metabolic impacts of fructose, are changing the traditional view that all calories are the same.

From a public policy perspective, governments and regulators have done little to address the impact of sugar consumption. Typical options often discussed, but rarely acted upon, include higher taxation as an attempt to reduce sugar intake while helping to fund healthcare costs related to obesity and diabetes, as well as increased spending on educating and explicit product labeling and warnings.

Worldwide, obesity now kills more people than starvation and malnutrition. The rapid growth of obesity, diabetes and related nutritional issues is arguably America’s top social health concern for which solutions can be devised to slow the growth and improve both health outcomes and costs.

And so, there is an opportunity to bring this social determinant of health into the mainstream of the health reform discussion. It’s a great example of the choices we can make to either continue to spend more money caring for the those medical maladies that come from the over-consumption of added sugars, or investing in a thoughtful response to increasing public awareness to deal with the root causes to slow the trend and improve the health of citizens.


For Consideration:

  • As part of health reform, what role, if any, should government play to address the growing implications in how the rapid rise of sugar impacts health status and eventually health costs?
  • Should sugar be regulated in ways similar to the treatment of other items that impact consumer health such as tobacco products?
  • Do you look at, or monitor, the level of added sugars found in the items you and your family consume? How does personal responsibility come into play when it comes to reducing the impact of sugar becoming a significantly higher portion of the average Americans caloric intake?

Additional Resources:

To go deeper on this topic:

“Sugar: Consumption at A Crossroads” by the Credit Suisse Research Institute

Get the Facts: Sugar-Sweetened Beverages and Consumption from Centers for Disease Control and Prevention (CDC)