In the summer of 2009 when the Patient Protection Affordable Care Act, also known as the Affordable Care Act (ACA) and Obamacare, was being widely discussed as a front burner political issue, I attended a town hall meeting held by my congressional representative, a moderate democrat, to listen to public comments before he decided whether or not to support the ACA. In the years following the disappointing implosion of healthcare reform during the Clinton administration, honestly, I did not expect to see the issue of healthcare reform back on the political agenda in my lifetime. So I was eager to attend and lend my support for a bill that would expand healthcare coverage for Americans and to hear my congressman respond to questions. When I arrived I was struck by the number of attendees and even more so by the large number of signs and placards with crude slogans linking ACA death panels, Nazism, killing grandma, etc. It was also striking that many of the people there were local working people who were members of the newly formed Tea Party and fierce opponents of the ACA. The negative views being expressed were passionate and urgent: Passage of the ACA would take our country down a path toward socialism, loss of freedom and government interference into the sacred domain of the physician-patient relationship.
Now that the ACA has passed both chambers of congress, signed by the president and ruled to be constitutional by the Supreme Court, there are still strong efforts by it opponents to stop its implementation. At present, the right wing of Republican Party in the house of representation has been willing to shut down our government and threaten default on our national debt unless the ACA is repealed or delayed. It is instructive to put the recent efforts to derail the ACA into historical context and see them as an extension of a century long effort, led by well-funded special interests groups to motivate American citizens through misinformation and scare tactics to vote against their own interests.
There have been a number of crucial points in the past 100 years of American history where proponents of reform initiatives to expand healthcare coverage were sanguine about their chances of success only to be defeated by a highly orchestrated and well-funded counter attack by special interest groups. Although Theodore Roosevelt supported expanded healthcare insurance the first real effort to expand healthcare coverage in 1915 came from the American Association of Labor Legislation (AALL), which was supported by the American Medical Association (AMA). By 1917 after the plan had been rejected by many state medical societies and disagreement erupted about the method of paying physicians, the AMA withdrew its support and denied ever having supported it. It is interesting that criticism at this point also came from both unions and commercial insurance companies. Unions worried that government would replace their role of providing social benefits and insurance companies feared a new, and more efficient, social framework for insuring citizens that included items like funeral expenses, which would undermine the multi-million dollar insurance industry. 1917 was also the year the US entered WWI and this marked the beginning of the effectiveness of government commissioned articles that linked universal healthcare with the risks of American moving toward the German socialism and Russian communism. The early progressive movement promoting healthcare reform, like many who followed them, did not realize how opposing interest groups could so effectively promote their own ideological and financial interests while simultaneously garnering public support from the very citizens for whom expanded the benefits of expanded healthcare were to be provided.
By the 1930’s as hospitals and their services were more frequently utilized by more Americans, the issue of how Americans were going to afford and pay for those services became an issue. The Committee on the Cost of Medical Care (CCMC) funded by 8 major philanthropic organizations whose members were a broad range of experts, had proposed by 1932 a system of voluntary health insurance as a way to cover these growing costs. Because some of its members favored compulsory health insurance, the AMA treated their report as a radical approach to implement socialized medicine. With millions of American out of work, the focus politically was on securing more benefits for the elderly, which would have been put at risk if healthcare expansion in general had been a goal. So it wasn’t until 1943, with the Wagner-Murray-Dingell Bill, that there was proposal for compulsory national health insurance and a payroll tax. Though many prominent leaders, including physicians, backed this plan, there was a fierce opposition that linked it with communism and myths of socialist world domination.
It is interesting that in 1944 governor Earl Warren of California had garnered broad support, including the California Medical Association, for a system of comprehensive healthcare insurance. However, it was the California Medical Association who hired two seminal pioneers in political consulting to wage a campaign against Warren’s plan and in support for Californians to purchase their own insurance privately. The two consultants, Clem Whitaker and Leone Baxter, spent their lives working jointly from the late thirties through the early fifties. Together they created aggressive, demagogic tactics to support big business by distorting the issues and instilling fear by associating whatever program they were working against with an established, mythical enemy. With the use of advertising slogans like “political medicine is bad medicine” being used in newspapers throughout the state, the support for Warren’s plan quickly diminished and it was defeated in 1945 by one vote. Political advertising using mass medical was not about informing, but about winning. That meant using tactics, however false and irrational, that worked to change and mold public opinion.
It was also the efforts of Whitaker and Baxter over a period of three years funded by the AMA at a total cost of nearly $5,000,000 that successfully scuttled Harry Truman’s proposal for national health insurance in the late 1940’s. In fact the AMA assessed member physicians an extra $25 each to help pay for this campaign which again effectively associated universal healthcare insurance with socialism and communism. The failure to expand government provided healthcare insurance was the framework in which unions negotiated benefits with employers, which resulted in the unique feature of the American healthcare system that links healthcare insurance with employment. But the game plan for undermining an effort to expand healthcare insurance, which persists to this day, had been defined in the 1940’s by Whitaker and Baxter.
The only grass roots movement by the late 1950’s to expand access to healthcare was on behalf of the elderly and the most vulnerable, which resulted in Medicare and Medicaid in 1965. As expected, the AMA opposed the initial plans and countered with a plan that included a voluntary program. Ronald Reagan summarized the prevailing conservative view in the following statement: “One of the traditional methods of imposing statism or socialism on a people has been by way of medicine. It’s very easy to disguise a medical program as a humanitarian project. Most people are a little reluctant to oppose anything that suggests medical care for people who possibly can’t afford it.” The linkage between universal healthcare and the threat of socialism runs deep in much of conservative political thinking. Richard Nixon was somewhat of an exception as he proposed a plan to reform the healthcare system through private insurance and to expand coverage in a manner that resembles what we see today in the ACA. Ted Kennedy resisted this approach and held out for an outright single payer system in the 1970’s. Certainly by the time Reagan became president, Kennedy’s noble aspirations were seen more and more as a liberal perspective not suitable for American capitalism.
In 1992 Bill Clinton campaigned on healthcare reform in 1992 and came into office with the unusual political capital to actually make reform happen. There was for a brief time a political consensus that healthcare reform was going to happen. Though the result was not going to be the robust single payer system Kennedy envisioned, but rather a more market based approach. Sadly, the plan that emerged became vulnerable to attacks for its complexity and also for not being more inclusive in its formulation. As soon as the criticisms began, all the traditional opponents of universal healthcare came on board and the effort quickly died. In retrospect, it should have been evident that conservatives were going to be against any healthcare reform plan a democratic president proposed. With the election of G. W. Bush, the prospects of healthcare reform were non-existent, except for Medicare prescription drug reform, which was a massive expansion of healthcare benefits, but one that failed to use the bargaining power of government to control cost and therefore caused a significant increase in the national deficit.
Though President Obama talked about healthcare reform in the 2008 campaign, though not universal coverage, and saw it as a fundamental structural barrier to economic progress, there were many challenges to getting it on the political agenda. In spite of many overtures of offers to cooperate from Republicans, by the summer of 2009 much time has been wasted on delay tactics and many of us thought the ACA proposal did not have a great chance to become law. Still it was the first time since the defeat of Truman’s plan that a real proposal had been presented for national discussion. It is somewhat ironic that the ACA was a plan similar to what Nixon had in mind in the early 70’s, and very similar to what the conservative Heritage Foundation came up with in the early 1990’s as an alternative to a single payer system, and basically what Mitt Romney passed and implemented in Massachusetts. But when Obama proposed the ACA it prompted well-funded conservative organizations to fund the Tea Party and with the help of right wing media outlets, the result was a wave of hysteria about the extremist nature of the ACA. This groundswell of public reaction in the form of the Tea Party was the basis for the GOP to take control of the House of Representatives in 2010; and, sadly, the moderate democratic representative from my district was defeated. Though the ACA is clearly on the conservative side of healthcare proposals, it has received criticism by the Tea Party as though it was a state controlled single payer system and with less than noble intentions about providing healthcare to Americans.
The political consulting work of Whitaker and Baxter was possibly the first use of mass media to control a political message. But in the subsequent decades it has been taken to a high political art and seems to permeate American politics. As our nation has grappled with a government shutdown and faced a national default on its debt, which would have had catastrophic consequences for both the national and global economies, one realizes how far out of touch contemporary American political discourse is with the healthcare challenges that face our nation. One also realizes the lengths to which special interests will go to prevent change in the current healthcare system so they can protect their own economic interests. The legacy of special interests vis-à-vis healthcare reform is not only a national disgrace but also has become a serious national liability to the future of our nation.
The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.
Karen S. Palmer. A brief history: Universal healthcare efforts in the U.S. (http://pnhp.org)
Jill Lepore. The lie factory: How politics became a business. The New Yorker (9-24-12)
J. Bade. The Heritage Foundation Designed Obamacare to Preclude Single Payer. Republicans Win Again! (www.my.firedoglake.com)
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BIOETHICS TODAY is the blog of the Alden March Bioethics Institute, presenting topical and timely commentary on issues, trends, and breaking news in the broad arena of bioethics. BIOETHICS TODAY presents interviews, opinion pieces, and ongoing articles on health care policy, end-of-life decision making, emerging issues in genetics and genomics, procreative liberty and reproductive health, ethics in clinical trials, medicine and the media, distributive justice and health care delivery in developing nations, and the intersection of environmental conservation and bioethics.