Efforts to implement national health reform in the United States.

Several years ago, Uwe Reinhardt, PhD, an economist from Princeton, sent out a Christmas card which excerpted results from polling data asking Americans their opinions of national health reform: Should we have universal health care in the United States? Eighty-five percent, yes. Whose responsibility is that? Seventy-five percent, federal government. How would you finance this? More taxes, sixty-five percent. Would you be willing to spend more than fifty dollars more a year in taxes to finance this? Twenty percent, yes. Merry Christmas." [1]

There is no public consensus as to what direction the United States should undertake in national health care reform. However, there is a renewed national debate and a sense of urgency regarding what the country as a whole should do about the following facts:

* 16 percent, or almost 40 million, of all Americans have no health insurance. [2]

* 25 percent of those who do have insurance have only partial coverage. [3]

* The poor who are eligible for Medicaid face numerous barriers to obtaining needed care. For example, JAMA recently published two articles that depicted how many individuals give up seeking emergency care after waiting for hours and often suffer adverse health outcomes. [4]

What form(s) should change(s) in the health care system take? There is no question that health care delivery has changed drastically over the past 10 years. However, the changes have occurred largely in how Americans are covered (the onset and firm entrenchment of managed care) rather than who is covered. In the past quarter century, little has changed at the national level. The passage of Medicare and Medicaid in 1964 represents the last major government efforts to radically restructure health care financing in an effort to increase access.

The series that this article initiates will attempt to accomplish two objectives:

* To actively engage physician executives in the national health reform debate. These articles will attempt to provide historical and political background to the heated debate that is currently under way.

* To historically highlight past and present involvement of physician executives in health reform, both at the local and the national level.

The remainder of this article will provide a synopsis of the different constituenies with an interest in national health reform, summarize the impact of American values on the potential for national health reform, and describe significant research that has been published recently.

Who Are the Actors?

Popular stereotypes of groups one might expect to be in favor of or in opposition to national health reform are often inaccurate. The views of the major interest groups affecting national health reform have frequently changed, depending on the leadership in power at the time and/or on specific historical circumstances. For example, for a brief period during the early 20th Century, the American Medical Association was in favor of national health reform. This support reflected the attitudes of the leadership in power at the time. This view quickly changed with the ascent of new leadership. The reasons for this change will be explored in a subsequent article.

Equally puzzling is th equivocal role of the American labor movement. Until recently, organized labor opposed government involvement in national health reform. Unions argued that health care coverage for employees and their dependents constituted bargaining issues to be negotiated solely between union and management. American labor's ambivalent stance toward national health reform was most recently reaffirmed during the 1991 AFL-CIO annual meeting, when the governing board split 10-10 on the question of support for a Canadian-style health care system.

Understandably, presidential politics has played a key role in the passage or defeat of federal health initiatives. The passage of Medicare and Medicaid was the culmination of efforts beginning with Harry Truman and the Democratic Party to legislate national health reform. Despite Truman's efforts, many interest groups, not the least of which was the American Medical Association, fought to defeat his health care legislative agenda. In his autobiography, Truman angrily denounced the AMA: "I have had some bitter disappointments as President, but the one that has troubled me most, in a personal way, has been the failure to defeat the organizational opposition to a national compulsory health insurance program. But this opportunity has only delayed and cannot stop the adoption of an indispensable federal health insurance plan." [2]

Among the policy and historical questionsd that still need to be examined are the extent of the popular basis for the AMA's position and how this popular support changed as AMA lobbying went into high gear immediately after Truman's unexpected reelection in 1948. What was the relationship between the structural interests of the AMA and those of other business groups, notably major corporations and insurance companies? To what extent was AMA opposition to compulsory, government-sponsored health insurance facilitated by the simultaneous jump in enrollment in voluntary health insurance, which began only in the mid-1940s? It will be important to attempt to assess the AMA's historical opposition to virtually all government health initiatives, in contrast to its present stance, in which it often works with federal and state governments.

The AMA was not the only interest group opposed to national health reform. Frequently the executive branch of government did not speak with one voice on national health reform. Constituencies from within the government helped to defeat Truman's legislative objectives in health care. World War II and its aftermath had a major independent impact on social legislation left over from the New Deal. Most welfare reform efforts went to veterans' benefits, rather than to changes in social benefits affecting the entire population. The new Veterans Administration developed into a political, bureaucratic constituency that was not in favor of national health insurance, because such a policy would reduce its own power base.

Foreign policy has often had a negative impact on the prospects for national health reform. The ending of World War II saw the heightening of tensions between the United States and the Soviet Union with the attendant labeling of much progressive legislation as communist or socialist. The cost of American foreign involvement has also frequently been cited as the reason for inadequate resources for domestic initiatives such as national health reform.

At least two upcoming articles will be devoted to Richard Nixon's failed effort to enact his "Family Assistance Plan." Ironically, many liberals would likely respond positively if such a legislative package were available today. However, in 1970, liberals demanded but were not successful in obtaining national health reform along the lines of the British National Health Services; that is, a health system funded and operated in its entirety by the federal government.

Several commercial insurance companies believed that federally organized national health reform would come to pass and began considering withdrawing from the health insurance business. These same companies are now the dominant players in the push toward managed health care. Many of these companies are portraying the effort to install managed care on a nationwide basis as the last best hope before a complete federal takeover of the health care system. While Richard Nixon failed to enact his brand of national health, reform, Ronald Reagan, the most conservative President since Herbert Hoover, was able to obtain passage of inpatient prospective payment (DRGs), the most regulatory legislation since Medicare and Medicaid. While certainly not national health reform, DRGs represented a major government effort at controlling payments to hospitals, the major cost driver in the health care system. Many policymakers would argue that President Reagan's conservative credentials were necessary for passage of the DRGs.

American Values

Several analytic perspectives are useful in examining efforts to legislate national health insurance (NHI) in the United States. While many authorities are fond of espousing theories that attempt to provide all the answers, it is unlikely that overarching unifying theories (such as Starr's cultural authority" [3] or Navarro/Waitzkin's "Marxist" approach [4]) adequately explain why the United States is the last Western industrialized country, outside South Africa, to have a national approach to health care. Each proponent of a political theory or ideology too closely attempts to pigeonhole historical data into a preconceived analytic framework.

American culture is influenced in the short term by events and conditions, such as the past hostility between the United States and the Soviet Union and, in the long term by underlying American values. How did these cultural values affect popular support for Truman's NHI proposal? What other short-term events influenced these cultural values? How strong was popular support for a government-sponsored health care program in contrast to the voluntary health insurance program that was exploding in membership in the mid-1940s? Did Americans in the immediate post-World War II era view NHI as a critical social benefit or one that coulsd be obtained within the framework of the new jobs opening up in the postwar economic boom? Can a thorough understanding of the historical record shed light on which of the following factors were more important in the ultimate defeat of Truman's NHI proposal: American cultural preference for private sector options, in the form of voluntary health insurance, or interest groups' efforts interests to marshal opposition to Truman's national health program. Such considerations will be an important part of each entry in this series of examination of U.U health policy.

Historical Perspective

In addition to analyzing historical events and cultural trends affecting national health reform, these articles will also direct readers to important research that has already been performed in efforts to institute fundamental changes in America's health care system. For example, there has been significant research on the overall impact of interest groups on American health policy at either local or national levels. For a theoretical understanding of different types of interest groups, the framework outlined in Robert Alford's book, Health Care Politics is particularly important. [5] Groups such as the American Medical Association and the National Association of Manufacturers are examples of "dominant structural" (Alford's term) interests, while the National Association of Public Hospitals represents an example of "repressed structural" interests. Alford's theories account for the historical finding that interest groups do not necessarily behave in accordance with other members of their economic class but instead advocate in favor of their own particular interest group needs.

As already emphasized, American cultural values also have influenced particular points in the NHI debate process. Researchers have adopted two different historical and sociological approaches to the analysis of American cultural values. Several historians, notably Gaston Rimlinger in Welfare Policy and Industrialization in Europe, America, and Russia [6] and the French cultural observer de Tocqueville, [7] point to an underlying continuity in American values and ideology and emphasize how these cultural values hav affected legislative outcomes. On the other hand, Robert Bellah, most recently in Habits of the Heart, [8] emphasizes subtle but important historical changes in American values. It is important to examine both of these perspectives in attempting to understand the importance of cultural values in any analysis of NHI legislative history. Did many of the NHI proposals fail merely because interest groups were powerful enough to defeat them, or did they also fail because of underlying American cultural discomfort with NHI? It is these very values that will likely shape the extent of future government involvement in NHI, determining, for example, whether NHI will be completely run by the government or will include the private sector. Cultural values, such as the much vaunted individualism, will also influence Americans' ability to choose providers and the types of health care to which they will have access. Of particular importance for today, American's cultural values will also determine whether rationing will apply only to the poor, as in Oregon, or to all classes of society, as in Canada.

Recent research has underscored the importance of interest groups from within the government bureaucracy. While federal and state bureaucracies may be weak by European standards, they can thwart or at least force amendment of health care legislation. In a recently published a collection of essays entitle The Politics of Social Policy in the United States, Weir, Orloff, and Skocpol contrast the development of professional bureaucracies in Europe, such as the well known English civil service with employees committed for life, with the delayed emergence of decentralized federal, state, and local administrative functions in the United States. According to these researchers, these weak bureaucracies, combined with an electoral democracy consisting of a two-party, historically patronage-dominated system in much of the U.S., led to the weak fabric of social legislation currently in existence in the United States.

Although the theoretical frameworks discussed above are of great assistance, they still do not explain why national health reform failed while other social programs, such as workers compensation, were enacted into law. The articles in this series will carefully analyze historical events from the theoretical perspectives outlined above and examine the historical record for factors that distinguish health care from other social benefits. How does the American mainstream viewhealth care and the government's role in its delivery? How has the view changed over time? While the Health Insurance Association of America (HIAA) and underdeveloped state bureaucratic functions clearly had a major impact on health-related legislative outcomes, this series will examine other factors that might distinguish health care from other social benefits. It will be important, for example, to trace shifts in historical trends of the oft-discussed belief in individual responsibility for health care vs. any societal obligation to improve individual health status.

The theoretical approach of the series will integrate history and ideology, because many of the interest groups, the tension between conflicting cultural values, and other factors are relevant to today's renewed national reform debate. In any effort to demonstrate the value of understanding past cultural trends and historical events, it is important to not simply reiterate the refrain that "history repeats itself." How does one choose the relevant trends and facts? A recently published book entitled Thinking in Time: The Uses of History for Decision Makers by President scholar Richard Neustadt and diplomatic historian Ernest May is instructive in this regard. Neustadt and May specifically ask what types of historical information from the past, for example the flu pandemic of 1918, would have altered government decision making in the swine flue affair of 1976. Simple regurgitation of the facts would not have provided assistance, according to Neustadt and May, in deciding which course to take in the swine flue affair. To make historical information useful for policy analysis, one needs to place it into reliable, valid, and policy-relevant frameworks.

There is no question that the debate over national health reform is heating up. Most physician executives are interested and many are actively involved in health reform at a total or national level. The articles in this series will, ideally, serve to sharpen the debate and recognize the pivotal role that physicians have had and continue to play in the shaping of public health policy.

References

[1] Ewe Reinhardt Christmas card.

[2] Truman Years of Trial and Hope.

[3] Starr's "cultural authority."

[4] Navarro/Waitzkin's "Marxist" approach.

[5] Robert Alford's book, Health Care Politics.

[6] Gaston Rimlinger in Welfare Policy and Industrialization in Europe, America, and Russia.

[7] The French cultural observer de Tocqueville.

[8] Robet Bellah, most recently in Habits of the Heart.

[9] Thinking in Time: The Uses of History for Decision Makers by Presidential scholar Richard Neustadt and diplomatic historian Ernest May.