Health reform at 100: What can we learn from a century of trying

Health reform in the United States has a history that stretches back almost a century. Present efforts are the latest manifestation of a campaign that began with Teddy Roosevelt, and presidents of both parties have presided over them. Studying these past efforts can put present controversies into context and provide clues to their likely outcome. From the start, major health reform was labeled “socialized medicine.” Franklin Roosevelt kept it out of Social Security for fear of the political effect. Harry Truman was thwarted by a skeptical Congress. John Kennedy tried unsuccessfully to gain passage of Medicare. The only major success was enactment of Medicare and Medicaid under Lyndon Johnson. He had unusual advantages, including overwhelming Democratic majorities in Congress and skills as a master legislative tactician. Subsequent efforts included proposals under the Nixon, Ford and Carter administrations, and the ill-fated Clinton plan of the 1990s. Two major Medicare expansions were enacted under Republicans: the catastrophic coverage extension under Ronald Reagan, although it was subsequently repealed, and the addition of prescription drug coverage under George W. Bush. Other than Medicare and Medicaid, did any of this lead anywhere? The answer is emphatically yes. Most efforts were often followed by incremental reforms that had major effects over time. For example, the Hill-Burton Act transformed hospitals, the HMO Act transformed health insurance, and SCHIP covers millions of children. Reforms under Obama, both big and small, will also leave a lasting impact in many important ways.