“I have some bitter disappointments as President,” reflected Harry Truman after leaving office, “but the one that has troubled me the most in a personal way, has been the failure to defeat organized opposition to a national compulsory health-insurance program.”
Harry S. Truman versus the Medical Lobby by Monte M. Poen examines proposals for national health insurance from 1914 to 1965 focusing on Truman’s efforts during his presidency.
About the Author
Monte M. Poen is Regents' Professor of American History at Northern Arizona University in Flagstaff. He is the editor of several books, including Strictly Personal and Confidential: The Letters Harry Truman Never Mailed and Letters Home by Harry Truman (both by the University of Missouri Press).
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Harry S. Truman Versus the Medical Lobby
The Genesis of Medicare
By Monte M. Poen
University of Missouri PressCopyright © 1979 the Curators of the University of Missouri
All rights reserved.
The Early Conflicts Over Health Security, 1915–1941
For Independence, Missouri, it was a typically hot and humid midsummer afternoon as the VIP-laden limousines paused at the door of the Truman Library. But for those who had come to gather in the air-conditioned comfort within, 30 July 1965 was a momentous day, a day that signaled the signing of the medicare bill into law, the most significant addition to the nation's old-age-insurance system since passage of the Social Security Act thirty years before.
No one relished that fact more than did the host of honor, former President Harry S. Truman, eighty-one years old and a bit unsteady afoot but still able to recall the prolonged and heated debate that had been generated over his national health insurance proposals back in the forties and early fifties. He had been, after all, the first president to endorse publicly the government health insurance idea; he had repeatedly asked Congress to enact it into law and had boldly carried the issue to the American people in the presidential election campaign of 1948. When organized opposition led by the American Medical Association had proved too strong and his comprehensive insurance program suffered defeat in Congress, it had been Harry Truman who shifted in early 1951 to a hospital insurance plan for the aged under social security, the precursor to medicare.
Now, fourteen years later, the former president was a "very, very happy man." Equally elated was his guest, President Lyndon Johnson, who had come to Missouri to pay tribute to Harry Truman and to sign into law America's first national system of governmental health insurance. It had "all started really with the man from Independence," President Johnson told the jubilant gathering; it had been Harry Truman who "planted the seeds of compassion and duty which have today flowered into care for the sick, and serenity for the fearful."
In the longer perspective of history, the Truman presidency in fact marked the midway point in a half-century of political maneuver and agitation that culminated in the passage of the Medicare Act. For it had been in the summer of 1915, three decades before Truman first asked Congress to legislate a health insurance program, that a small group of social workers and reform-minded economists launched the initial American health security campaign, adopting the slogan "Health Insurance—the next step." These socially attuned pioneers did not get very far with their ventures, it is true; and their movement was largely restricted to lobbying for industrial-sickness-insurance schemes on the state level. But the ideas they developed, the people they inspired, and the organizational methods they used all became part of a second and even more ambitious legislative drive during Franklin Roosevelt's presidency in the depression thirties and of the post–'World War II movement.
This early effort to secure governmental insurance against sickness arose from the buoyant optimism and crusading spirit that characterized the Progressive movement, a mighty reform impulse unleashed at the turn of the century by societal stress born of the nation's recent industrialization and urbanization. It was a time when social workers, journalists, educators, ministers, and some labor and business leaders discovered inequities and poverty in America and set out to do something about it. As pioneer medical social worker Ida Cannon recalled, the century's first decade saw "great personalities loudly calling for social justice and for more attention to the conditions of living in our cities and of work in our factories." Poverty and social injustice had to be eliminated, and to people like Ida Cannon and the other members of her emerging social-work profession, there was a close link between the ills of society and the impaired health of the individual.
The example of successful movements abroad for governmental insurance schemes provided additional inspiration for American reformers. First in Germany in 1883 (one year before Harry Truman's birth), and then in other European industrial nations, programs had been established to protect workers against the economic calamities that accompany sickness and industrial accidents. By 1911 nearly every major European nation, including England, had legislated some kind of tax-supported health insurance program.
In the United States, social workers in alliance with political activists called attention to the need for similar protection for the American laborer. Working through charity societies and philanthropic enterprises like the Russell Sage Foundation and the Milbank Memorial Fund, they gathered fat volumes of social statistics on accident and disease; by the end of the century's first decade, the social reformers were deeply involved in legislative campaigns to provide better housing, to control tuberculosis and venereal disease, and to eliminate industrial health hazards. The next step was to convince the public that government-sponsored insurance programs were essential.
The educational effort proceeded on many fronts. The Sage Foundation sponsored a two-year study of European social insurance programs and in 1910 published a laudatory report, Workingmen's Insurance in Europe. The same year, Henry Seager, a noted political economist, delivered the first American lectures on social insurance at the New York School of Philanthropy; shortly afterward the school sponsored another series of talks on the subject by physician, economist, and social worker Isaac Rubinow. Both Seager and Rubinow stressed that an industrial society needed a state-supported insurance system to protect against sickness and poverty. A similar message appeared in the influential social-work magazine, Survey. Starting in 1911, readers of Survey were exposed to articles that praised the recently enacted British insurance system and demanded that similar protection be provided American workingmen.
Gradually a social-work group, the National Conference of Charities and Correction, began to serve as an organizational catalyst, transforming individual inquiry and uncoordinated promotion into a cohesive reform movement. The NCCC had shown sporadic interest in devising an American insurance plan since 1902, appointing commissions and holding discussions on the topic; and the group had become quite serious about the issue by 1911, the year Louis Brandeis gave an electrifying address to its annual meeting. Brandeis was already famous for his precedent-shattering sociological brief at the time that the Supreme Court upheld Oregon's law limiting women to a ten-hour workday. Now, he urged his listeners to work for the adoption of social insurance to cover "sickness, accident, invalidity, premature death or premature old age." The NCCC responded to Brandeis's challenge the following year by unveiling its "Platform of Industrial Minimums," a comprehensive reform program to guarantee the worker basic protection against economic ruin.
Since 1912 was a presidential election year and the Republicans were convening their national convention as the NCCC meeting drew to a close, a few of the NCCC delegates attempted to have their reform platform adopted by the GOP. When the conservative-dominated Republican platform committee rejected their proposals and the contested delegation pledged to former President Theodore Roosevelt bolted the convention, the social workers followed Roosevelt to the new Progressive party. Even though health reformers distrusted Roosevelt, doubting his sincerity as a true champion of domestic reform, they recognized that the former president might endorse their ideas and thus further their cause. Consequently, when Roosevelt did accept the NCCC program as an important part of his Progressive party's platform, the social workers enthusiastically joined him at Armageddon, backing the Roughrider in his campaign to recapture the presidency.
Woodrow Wilson's defeat of Roosevelt in 1912 disappointed health reformers, but it was not totally unexpected. Besides, there was heartening news concerning the results of investigations conducted by numerous state commissions on the need for, and the feasibility of, workman's accident-compensation programs. The previous year, ten states had established such systems, and more important, the courts (which had declared earlier attempts unconstitutional) had begun to validate state-sponsored insurance schemes.
The organization most responsible for this development was the American Association for Labor Legislation. Founded in 1906 by reform economist Richard Ely and his associates, the AALL, in alliance with the social workers, investigated industrial working conditions, drafted model legislative proposals to eliminate major occupational hazards, and lobbied for their enactment. The AALL's first legislative campaign had resulted in the elimination of phosphorus, a very toxic and crippling substance, from use in the manufacture of matches. With this accomplished, the association began lobbying for state systems of accident compensation, an effort that achieved its greatest momentum in 1911.
Still, accident insurance did not protect the worker against disability incurred from sickness, so Miles Dawson, insurance expert and coauthor of the Sage Foundation-sponsored Workingmen's Insurance in Europe, took the floor at the 1912 AALL meeting to urge that the association back a governmental health insurance scheme like that in Germany. Soon the AALL Committee on Social Insurance, with Edward Devine, founder of Survey, serving as chairman, had arranged for a conference on social insurance to meet the following year. Held in Chicago, the conference concentrated mainly upon the need for health insurance, and when the AALL gathered for its own meeting later that year, sickness compensation dominated the discussion.
By June 1914, the accelerating health security campaign had reached the point where Edward Devine thought that America stood on the verge of "The New Health." "We are now at a point in our economic development," announced Devine, "wherein we can devote the fruits of abundance to the health of all. The prime characteristic of the New Health is that it is social, not self-centered; to be won by all together by corporate effort."
The following year the AALL began to agitate for state systems of health insurance. Meeting with association secretary John Andrews, social workers Jane Addams, Paul Kellogg, Edward Devine, and Isaac Rubinow launched the legislative campaign, adopting the slogan "Health Insurance—the next step." In July 1915, the AALL's Social Insurance Committee issued its nine "standards" for a health insurance law, and by November the first tentative draft of its standard bill was published. If enacted, workers who earned less than twelve hundred dollars annually would receive a cash benefit equal to two-thirds of their weekly pay as well as contracted medical care in case of sickness. The standard bill also contained a funeral payment. To distribute the burden of its costs, financing would be divided equally between the employee and his employer, with the state providing 20 percent. Local insurance societies, supervised by the state's social-insurance commission, would administer the program.
At first the standard bill appeared to be following the same path to legislative success as did the workmen's accident compensation for industrial workers. By the time Isaac Rubinow undertook a cross-country examination of the spreading health insurance movement in 1917, thirty-one states had already passed compensation laws, and health insurance bills had been introduced in twelve of them. Laboring men would soon be protected from sickness as well as from injury, Rubinow reported optimistically; every stage of legislative evolution was under way, all, that is, except the final stage of enactment.
The biggest effort came in New York and California. The first in a series of health insurance bills was introduced in the New York legislature in 1916, and two years later California health reformers, bolstered by a favorable report from the state's Social Insurance Commission, sought an amendment to the state constitution to assure the legality of their plan. Although California voters defeated the amendment in 1918, another insurance commission soon formed and it, too, recommended adoption of a state-supported program. At the same time, Gov. Alfred E. Smith assisted the movement in New York by sending a special message to the legislature endorsing a health insurance bill. The state senate held public hearings on the legislation in the spring of 1919, and after a few weeks the senate passed the measure; things looked so favorable in Albany that the Rochester (New York) Democrat predicted its passage into law.
The elation was premature, however. Because of the obstructionist tactics of the conservative speaker of the house, the New York assembly version of the bill never reached the floor for consideration. In California and elsewhere similar health measures failed to get beyond the committee stage. For more than a decade thereafter the government health insurance movement lay dormant. As one observer noted, "Society's feet, taking 'the next great step' in social progress, remained in mid-air."
It was not easy to overcome the intellectual and institutional barriers and gain quick acceptance of such a system. Indeed, many of the problems then confronting American health reformers would continue to frustrate health security advocates over the next four and a half decades. While attitudes concerning the government's societal responsibility had begun to change at the turn of the century, many Americans still believed that sickness and impoverishment were private affairs, the sole concern of one's family, or, at most, of private charity, the local poorhouse, or the church. Also, being required by the government to help pay for a system to protect the sick and the poor ran counter to traditional beliefs in restricted government and individual liberty, against frontier-bred tenets that consider centralized authority and its tax-collecting agents to be somehow un-American.
Moreover, the nation's political institutions acted, then as now, like brakes, slowing up the process of social and economic reform. It is no accident that medicare, the first system of national health insurance (and a limited one at that) was enacted in 1965, more than a half-century after Great Britain and the other major European countries had legislated programs of much broader scope. As James Bryce noted long ago in his The American Commonwealth, "There is an excessive friction in the American [political] system...Power is so much subdivided that it is hard at a given moment to concentrate it for prompt and effective action." Because this power is not only diffused through a federated system of semisovereign states but is also divided within the state and national governments between the executive, legislative, and judiciary branches, any one of the constituent parts, if out of step with the others, serves as a barrier to social change.
This is the major reason that the initial drive to secure social-insurance legislation in this country originated and remained confined largely at the state level; a federally sponsored compensation program was considered to be unconstitutional. After President Franklin Pierce's 1854 veto of Dorothea Dix's national mental health bill (on the grounds that the government had no business getting involved in its citizens' health problems), private groups and local government authorities increasingly assumed primary responsibility for sick and elderly indigents. By 1900 a vast network of county poorhouses dotted the countryside, while in the crowded city, political machines, settlement houses, and soup kitchens tended in sporadic and inadequate fashion to the minimal needs of the industrial poor.
Even when progressive reformers did begin to win some legislative victories in their fight to make accidents, sickness, and impoverishment a state responsibility, the courts at first struck down as unconstitutional many of their public-sponsored programs. By interpreting the Fifth and Fourteenth amendments to the Constitution in a way that sanctified the power of private contract, the judiciary, from the 1880s until 1937, curtailed the police power of government, blunting many state and especially national attempts to regulate the conditions of labor.
Compounding the divisive and uncomplementary instruments of American government were the loosely organized, coalition-type political parties. Their inability to legislate quickly in the absence of a national crisis such as war, the threat of war, or economic depression, or, as in the case of the Kennedy assassination, in the wake of a national crisis, served as another obstacle to enactment of major reform. Most important, this lack of party cohesion and ideological commitment granted, then as now, powerful special-interest groups—the ubiquitous lobbies—inordinate influence in the legislative process. Unprotected and little assisted by their national political party affiliation, whether it be Democratic or Republican, congressmen and state legislators must look beyond the party organization for publicity, finances, and votes to get elected; they also need information and drafting assistance on complex legislative proposals. For a price, lobbies have gladly filled their needs.
Excerpted from Harry S. Truman Versus the Medical Lobby by Monte M. Poen. Copyright © 1979 the Curators of the University of Missouri. Excerpted by permission of University of Missouri Press.
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Table of Contents
1. The Early Conflicts over Health Security, 1915–1941,
2. A Presidential Health Program: From FDR to HST,
3. An Uncertain Beginning, 1946,
4. A Trying Time, 1947,
5. Politics and Health: The 1948 Presidential Campaign,
6. A Testing Time, 1949,
7. Politics, Then Health: The Medicare Compromise,
8. The Reality: From HST to LBJ,