Thursday, December 16, 2010

Where It All Began

Justin Kimball
In 1929, Justin Kimball, then a vice president of the Baylor University medical extensions in Dallas, reflected on a pile on unpaid hospital bills, many of them from teachers. He proposed a prepaid plan wherein for $6 a year, Dallas teachers would receive up to 21 days of hospitalization. The idea proved popular, and soon 75% of Dallas teachers were enrolled. From this modest beginning, the American health insurance business took root.

Meanwhile, the ravages of the Great Depression influenced New Deal policy makers to urge President Franklin Roosevelt to propose a national policy of guaranteed health care. But Roosevelt's attention was preoccupied with other legislative priorities and with conducting World War II. Moreover, he shied away from battles with the American Medical Association and southern segregationists, who feared that a national plan would lead to integrated hospitals.

Harry Truman, Roosevelt's successor, felt a stronger commitment to guaranteed health care and made it a central platform of his remarkable reelection campaign in 1948. But after Congress rebuffed an initial effort, Truman set health care reform aside in favor of other priorities. Still, he had proven its resonance as a political issue, so much so that the next president, Dwight Eisenhower, searched for a public-private alternative to the federal program he feared was coming.

Eisenhower could never make a public-private plan pencil out, but he did articulate a conservative alternative for health care reform. More importantly, he signed the Revenue Act of 1954, which formalized a wartime regulation making employer-provided health care expenses tax deductible. Employer-provided insurance became a cornerstone of compensation, and by the end of the decade more than 50% of Americans had health insurance coverage.

Two groups, though, did not: the elderly and the very poor. In 1962, John Kennedy sought to change that, undertaking a national crusade for Medicare legislation that was unable to surmount Congressional opposition. Kennedy lacked the legislative skills necessary to pass Medicare, but Lyndon Johnson did not. With his able guidance, Medicare/Medicaid became law in 1965.

Liberals, led by Senator Edward Kennedy, continued to pursue a single national health program for all. Seeking to blunt their momentum, Richard Nixon advocated a public-private partnership based on the emerging concept of managed care. Watergate weakened Nixon politically, and Kennedy would later regret not having allied himself with Nixon on this issue.

Kennedy's primary defeat by Jimmy Carter and Ronald Reagan's subsequent election spelled the end of the liberal push for national health insurance or a single-payer system. Bill Clinton's complex effort, which collapsed under its own weight, contemplated neither. Republicans had prepared an alternative approach based on mandates, but pulled it once it became apparent that the Clinton plan would not succeed.

The presidency of George W. Bush saw passage of Medicare Part D, which offered prescription drug coverage through a public-private mechanism. Though complex and unfunded, Part D proved popular despite its inadvertent creation of a "doughnut hole," which left uncovered a middle tier of expenditures. Meanwhile, in 2006, Massachusetts Democrats teamed with Republican governor Mitt Romney to pass a law requiring all residents to obtain state-regulated minimum coverage.

In 2009, President Barack Obama proposed what in became 2010 public law 111-148, also known as the Patient Protection and Affordable Care Act. Health Matters will review the ACA in detail; for now, it is enough to say that it stems from the public-private values originally envisioned by President Eisenhower, that it tracks closely to the Massachusetts law, and that -- ironically -- it takes advantage of policy alternatives proposed by Republicans in the 1990s.

Unfortunately, opposition to ACA concentrated on defeating political adversaries; as the war of words escalated, the quality of the discourse degenerated and the country missed a chance to debate health care reform in meaningful terms. It is not true, for example, that the ACA funds death panels, nor is it socialist. (There is a such thing as socialized medicine; the ACA isn't it.) It is also not the case that the leading conservative alternative to the ACA amounts to "get sick and die."

America needs an honest debate about health care reform: The stakes are high and the issues are so complex that it makes no sense to discard tools and alienate each other on the basis of ideology. After all, we'll all need health care eventually, and we want the health care that we get to be both affordable and good. Unfortunately, today there is no guarantee of that despite the best efforts of dedicated, highly trained doctors and nurses with access to world-class health care technology.

That must change.