Long history of struggle lies behind court decision
Lawrence A. Powell world watch
Thursday's decision by the United States Supreme Court to uphold the constitutionality of Barack Obama's reforms, availing health-care insurance to another 32 million Americans, has been hailed as a landmark victory for citizen rights and a potential boost for the president's 2012 re-election bid.
"The highest court in the land has now spoken," he boasted, basking in the glory of the moment. "I'm as confident as ever that when we look back five years from now or 10 years from now, or 20 years from now, we will be better off because we had the courage to pass this law."
His Republican opponents, however, were in vitriolic disagreement, ridiculing the law as "big government" gone mad, and with 2012 presidential challenger Mitt Romney immediately promising to repeal the measure if elected. "Obamacare was bad policy yesterday. It's bad policy today."
Long legacy of struggle
Similar sentiments, on both sides, have been voiced before, many times. Historically, this recent court case is merely the tip of the iceberg of a long, bitter struggle between reactionary private interests and progressive public health-care advocates in America. Although the United States is the world's wealthiest nation, able to lavish vast sums on a global military presence, it has for many decades now had the embarrassing onus of being the only remaining modern industrial democracy that fails to ensure access to medical coverage for its own citizens.
Even with this recent Supreme Court decision under its belt, it still does so only partially, and reluctantly, in comparison to other modern nations. Moreover, if Republicans should defeat Obama and prevail in the upcoming November election, they have vowed to repeal the new law that ensures even this partial coverage.
But at least for the moment, the extension of medical insurance availability to the millions of Americans who could not previously afford it, as well as the important clause prohibiting private insurers from denying medical insurance coverage based on "a pre-existing condition", are major positive steps in the direction of providing the kind of comprehensive national health programmes long since achieved in Canada, Britain, continental Europe, and the rest of the industrialised world.
The Patient Protection and Affordable Care Act ('Obamacare'), which Obama and the Democratic Party were finally able to push through Congress during the early months of his 'honeymoon mandate' phase in 2009, and whose constitutionality has now been affirmed, was in fact the culmination of a protracted, century-long political struggle in the US ‹ spanning the administrations of presidents Theodore Roosevelt, Franklin Roosevelt, Harry Truman, John Kennedy, Lyndon Johnson, Bill Clinton and, finally, Barack Obama.
Early European precedents
In Europe, the precedent of national health insurance as a guaranteed citizen right had already been established by the turn of the 20th century. Germany, under Bismarck, was providing health-care insurance for its workers as early as 1883, with the Sickness Insurance Act.
And in Britain, in 1911, Lloyd George and the Liberal party passed their National Health Insurance Act, providing medical insurance for low-income workers as part of a social-security pension programme. By 1940, every nation in Western Europe had enacted a national health insurance plan covering at least its low-income citizens, and most of these plans were quite comprehensive.
Not so in the US. Despite citizen pressures for government to become involved in health care that date back to the early 20th century, Americans remained without any significant national coverage at all until 1965, when Medicare (providing limited coverage to the aged) and Medicaid (providing limited coverage to the poor) were finally passed during the Johnson administration as part of his 'Great Society' legislation. This, however, still left the majority of Americans without public-health coverage, and hence at the mercy of unscrupulous, poorly regulated private insurers who were reluctant to make insurance affordable, to take risks, or to pay out the health-insurance claims.
From Roosevelt to Obama
The American Association for Labour Legislation had attempted, between 1915 and 1918, to secure passage of a medical-insurance bill in several of the state legislatures, but the effort was promptly blocked by well-entrenched local medical societies who vehemently opposed any form of publicly provided insurance. In 1920, the American Medical Association unambiguously voiced its opposition to "any plan embodying the system of compulsory contributory insurance against illness ... which provides for medical service to be rendered to contributors or their dependents, provided, controlled, or regulated by any state or federal government."
The first genuine attempt to move in the direction of guaranteeing public health insurance for US citizens came during the Great Depression, in the mid-1930s, when President Franklin Roosevelt and his Committee on Economic Security briefly toyed with the idea of adding a medical-insurance clause to their proposed social-security bill (which proposed old-age pensions and unemployment compensation to counteract effects of the deepening depression).
The effort did not last long politically. The inclusion of just a single line in the bill, which suggested that the committee study the possibility, and then report to Congress, caused such a furore that the clause had to be immediately withdrawn. As the director of Roosevelt's committee, Edwin Witte, later explained, "That little line was responsible for so many telegrams to members of Congress that the entire social security programme seemed endangered until [we] struck it out of the bill."
With no government health insurance yet available to Americans, a flurry of related bills were introduced in Congress annually in the 1940s. But despite substantial popular support for the concept, and endorsement by President Truman and Democratic Party majorities, the various national health-care insurance proposals were repeatedly "killed in committee" before they could reach the floor of the House or Senate for debate. This reflected intense lobbying campaigns launched by special interests, designed to protect the financial interests of the private medical profession and the related drug, hospital and insurance industries, which combined with unyielding ideological opposition from southern Democrats and Republicans to make health-care reform impossible.
Things began to look more favourable for change in the 1950s and 1960s. Congressional reformers, repeatedly unable to push through a comprehensive insurance package that would cover the whole population, shifted to an 'incremental' strategy, that would first get a foot in the door by arguing for minimal care for the elderly and poor, then expand to the entire population once the principle of public health care was legitimised.
Also, a new labour-senior alliance developed between 1958 and 1965. Unions like the United Auto Workers and the AFL-CIO joined forces with senior organisations like the National Council of Senior Citizens and the American Association of Retired Persons to create a much more powerful lobby on Capitol Hill. This labour-senior coalition, combined with the ascendance of progressive Massachusetts senator John F. Kennedy to the presidency in 1961, reignited hopes of reform.
In his first message to Congress, Kennedy proposed that pension benefits (earlier passed into law in Roosevelt's Social Security Act of the 1930s) now be extended to cover hospital and nursing-home costs of the aged. He tried to reassure opponents that this was "not socialised medicine" but, instead, a new programme of "prepayment for health costs" which would guarantee "absolute freedom of choice" in which "every person will choose his own doctor and hospital". Sound familiar?
Congressional Republicans and southern Democrats again mobilised to block "the entering wedge of the socialised state", arguing that publicly provided medical care, even for just the elderly, was too "dangerous to the principles underlying our system of medical care". But this time, in the mid-1960s, conditions were riper for legislative change.
In the wake of Kennedy's assassination, Lyndon Johnson's landslide victory in 1964 and the largest Democratic Party congressional majority since the Roosevelt years made possible the passage into law of a compromise Medicare-Medicaid bill in 1965. Though the law was, by European standards, merely a scaled-down version of limited medical insurance for the aged (Medicare) and the indigent (Medicaid), this was a landmark achievement for the more laissez-faire liberalist American context. However, it still left most of the population with either no or limited public health coverage.
The next major attempt to expand coverage, to all Americans, rather than just the old and poor, came during the Bill Clinton administration, in the early 1990s. Fresh from an election victory, Hillary Clinton painstakingly put together a massive 1,300-page government health-care proposal under the president's direction, which they then presented to Congress to be passed 'as is'. President Clinton insisted that he would not sign any resultant bill that did not guarantee universal health care. As a result of their rigid approach, and an intransigent Congress, the proposal did not even get to a vote.
Obama's place in history
So in historical perspective, as viewed across a hundred years of similar political struggles, Obama can be said to have accomplished something truly unprecedented - in first getting this "affordable health-care-for-all" legislation through the House and Senate (though in a watered-down form), and then enacted into law, and then getting the constitutionality of its essential elements vindicated by the Supreme Court.
Whatever other mistakes he may have made, or may make in the future - this rare political accomplishment will go down in history as unique, and will surely be appreciated by the approximately 32 million Americans who are now able to afford decent health care, as well as those who no longer have to worry about being turned down by insurance companies because they have a 'pre-existing condition'.
Lawrence Alfred Powell is honorary research fellow at the Centre of Methods and Policy Application in the Social Sciences at the University of Auckland, New Zealand, and former polling director for the Centre for Leadership and Governance at UWI, Mona. Email feedback to firstname.lastname@example.org and email@example.com.