THE FAIR DEAL UNIVERSAL HEALTH CARE PROPOSALS: HISTORIANS' PERSPECTIVES FROM 1970 TO 2003.

• Author: Horvath, George

INTRODUCTION

Proposals to expand publicly financed health care coverage--Medicare-for-all plans, a public option, Medicare and Medicaid buy-in plans--are at the top of the public's (and many political candidates') interest. (1) With that interest, the progressives' longtime goal of universal health care coverage once again seems poised to take on new life. (2) Although publicly financed coverage was dramatically expanded in 1965 by Medicare and Medicaid, (3) and in 2010 by the Affordable Care Act, (4) none of these programs can claim the mantel of truly universal coverage. (5) This Article recalls the last attempts at achieving universal coverage in the United States. Throughout the Truman administration's Fair Deal era, ideas for a national system of publicly financed universal health care were developed, debated, and even proposed in Congress. (6) But in spite of public support for health care reform, each legislative proposal that embodied these ideas failed. (7) These failures, and historians' evolving accounts of why the Fair Deal proposals tailed, offer important understandings into the current moment, and might even suggest ways to move reform forward.

Historians who have examined the failure of the Fair Deal proposals have generally agreed that opposition from within Truman's own Democratic Party and from congressional Republicans, combined with opposition from organized medicine, contributed to the ultimate failure of the proposals. (8) But an examination of the accounts of the Fair Deal health proposal failures written during a period beginning shortly after Medicare and Medicaid were enacted and ending amid President George W. Bush's calls to privatize Medicare and Social Security (9) shows that over time, historians' interpretations of the failures shifted in two major ways. First, historians' answers to the question of why the proposals failed changed. (10) Over time, the roles played by politicians opposed to the programs and by organized medicine were viewed as less central to those failures. (11) And second, historians began to ask a broader set of questions than simply "why did the proposals fail?" (12) Later historians in this period asked about the ways in which the "universal" programs, had they been enacted, would have neglected many marginalized groups, and about the larger impacts of the proposals' failures. (13)

This Article begins in Fart I with a brief history of the Fair Deal proposals for a public, compulsory, universal system of health care coverage. In Part II, the accounts of six historians, written over a period of thirty-four years, are examined, with a focus on the factors to which each attributed the proposals' failures, and on the broader implications--if any--that each historian addressed. Part III posits that two developments during the period in which these historians worked--the ascendency of a new conservative movement and the failure of the Clinton health care plan--partially account for the changes in their interpretations of the Fair Deal health proposals. Finally, in Part IV this Article extracts some lessons from the Fair-Deal proposals failures and from historical accounts of those failures.

1. THE FAIR DEAL PROPOSALS FOR UNIVERSAL HEALTH CARE

   The features that set the Fair Deal health care proposals apart from those that preceded them were their goals of creating a national program of coverage that was both universal and compulsory. (14) Earlier efforts had aimed at enacting coverage programs on a state by state basis or at establishing a voluntary national program. (15) Although the shift to compulsory, universal, nation-wide coverage began late in the Franklin Delano Roosevelt administration. (16) President Truman and his Pair Deal supporters were the first national politicians to advocate such a program. (17) This Part briefly recounts the legislative history of the Fair Deal proposals in order to provide a background for the historical accounts of those proposals that the Article then examines.

   After the Progressive reformers' efforts to enact state-based universal health coverage failed in the World War I era, a private group of "physicians, health officers, social scientists and representatives of the public" assembled in 1927 to form the Committee on the Costs of Medical Care (CCMC). (18) The CCMC's majority report, issued in 1932, advocated for a program of "[c]omprehensive medical care... provided largely by organized groups of practitioners... [with] costs... placed on a group payment basis, whether through insurance, taxation, or both." (19) Although the report offered a choice of voluntary and compulsory programs, most members of the CCMC preferred the voluntary approach to prepaid health insurance. (20)

   In 1934, President Franklin D. Roosevelt created the Committee on Economic Security (CES), which was tasked with evaluating "proposals for a long-term social security program." (21) Although the CES considered ideas for a federally-run program of health care insurance, health care coverage was not included in Roosevelt's proposals to Congress out of fear that its inclusion would doom the Social Security Act of 1935. (22) Following the passage of the Social Security Act, the Public Health Service commissioned a series of studies including the National Health Survey that examined "the incidence of illness and the underlying social and economic factors" at the time. (23) But like the CCMC report, the CES ultimately recommended a comprehensive program for health insurance, but left open the question of whether the program should be voluntary or compulsory. (24)

   In 1939, Senator Robert Wagner of New York proposed the First Wagner Bill, which incorporated a national health insurance program, including the CES's medical insurance recommendation. (25) The Wagner bill was never reported out of committee. (26) In 1943, Senator Wagner, now joined by Senator James Murray and Congressman John Dingell, proposed the first of the Wagner-Murray-Dingell bills that formed the basis of the Fair Deal universal health care proposals. (27) For the first time, a proposed health care bill called for a compulsory program, with health care to be paid for by a social insurance system funded by payroll taxes. (28) The bill had the tacit support of President Roosevelt, but was not enacted. (29)

   In November 1945, less than a year after assuming the presidency following Roosevelt's death, President Truman sent Congress his own health care proposal. (30) Truman's proposal was phrased in universal terms, calling for the recognition that "[e]veryone should have ready access to all necessary medical, hospital and related services." (31) The proposal was mandatory: Truman urged Congress to enact a program that would "distribut[e] the costs through expansion of our existing compulsory social insurance system."' (32) Truman's proposal specified that coverage for workers and their dependents would be prepaid through a payroll tax, while coverage for "needy persons" would be paid for by "public agencies." (33) In his message, Truman stressed that although private, voluntary health insurance existed, only three or four percent of Americans had comprehensive coverage. (34) Attempting to avoid the anticipated counterattacks, Truman insisted that his program was not "socialized medicine." (35)

   Versions of the Wagner-Murray-Dingell bill were reintroduced annually during the Fair Deal era. (36) Opponents put forth competing proposals. (37) The most prominent of these was Senator Robert Taft's 1947 bill that offered coverage only for the indigent, with a needs test for eligibility and strict limitations on the benefits. (38) Although Truman repeated his calls for Congress to enact a compulsory, universal health coverage program between 1947 and 1949, (39) by the 1950s the dream of universal coverage had ended. Proponents of national health care had begun to focus on more limited proposals that would cover the elderly, survivors of wage earners, and the disabled, (40) which would, fifteen years later, materialize into the Medicare and Medicaid programs.

2. HISTORIANS AND THE FAILURE OF THE FAIR DEAL HEALTH COVERAGE PROPOSALS

   The earliest historical accounts of the Fair Deal proposals focused on the political dimensions of the efforts' failures. (41) In his 1970 The Politics of Medicare, Theodore Marmor used the history of the "origins, evolution, enactment, and consequences of Medicare" as a case study to examine certain aspects of U.S. politics and public-policy. (42) Marmor's discussion of the Fair Deal health proposals' failure is brief, and is used to frame questions about why Medicare was created at the time and in the form that it was. (43) His thesis is that, although a strong majority of Americans favored a program of "government assistance in the financing of personal health services," any specific proposal was bound to be highly controversial; (44) because of this, the only way that proponents could have enacted a proposal would have been through a combination of several factors, including

   * sufficient organization by the proponents to counter the inevitable opposition;

   * broad agreement on the problem to be solved and the available remedies;

   * strong support from executive branch agencies;

   * insiders' commitment to navigating a bill through the legislative process;

   * and most importantly, a reliable voting majority in both houses of Congress. (45)

   In Marmor's view, the absence of nearly all of these factors contributed to the failure of the Fair Deal proposals. (46) Relying on official government reports from 1965. and on the first-hand knowledge of Truman administration insiders, Marmor attributes the failure in large part to "the absence of a programmatic [voting] majority in the Congress." (47) Although he does not identify Truman's congressional opponents during the first two years of his presidency--when Democrats controlled both houses of Congress--Marmor is clear...