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Why health-care reform gets harder over time


This is a good Slate explainer looking into whether the health-care reforms of the early-20th century actually had a health-care system to reform. The answer, basically, is no, and for reasons I'll explain, that should make us very skeptical of rejecting this latest attempt at reform.

In 1870, there were only 112 hospitals in the United States, probably because doctors couldn't do much to help patients other than hacking off limbs or sedating them with morphine. (Morphine was available over the counter until 1914, anyway.) Hospital patients were mostly poor people who couldn't work and had no one to care for them. The wealthy, meanwhile, paid for home-based care. Even amputations were frequently performed in a patient's home. But starting in the 1890s, hospitals became much more useful. Doctors could treat diphtheria and see inside the body with radiography. Surgeons began working in aseptic operating rooms, enabling them to open the chest cavity and remove diseased organs. In the 1900s, new diagnostic tools like the Wasserman syphilis test became available. Medical schools moved from two-year curricula — with the second largely repeating the first — to four-year, science-based programs that included practice sessions at hospitals. By 1920, there were 6,000 hospitals nationwide.

When the working class began to clamor for access to the new technologies, Roosevelt's Progressives were the first major American party to pick up the baton of health care reform. (Germany had a compulsory health-insurance program since 1883, and the British National Insurance Act passed in 1911.) While the party platform offered a vague endorsement of a socialized insurance system, Progressives pushed a much more specific program in state legislatures in 1915. Participants and their families would be guaranteed all medical and hospitalization expenses, income replacement for up to six months, $50 for funeral expenses, and complete coverage of labor and delivery costs with an eight-week maternity benefit. The plan would cost about $2 per worker, with the expense split between employers ($1.20), workers (40 cents), and the state (40 cents). All workers earning less than $100 per month would be required to participate, and the burden on the employer would increase for particularly low-wage laborers.

Over the past hundred or so years, the health-care system has gone from a very small portion of our economy to about a fifth of it. That's a remarkable rise. And it has been accompanied by a similar rise in the political power of the health-care industry. I've previously argued that the history of health-care reform is a history of decreasing ambition: FDR and Harry Truman propose something like single-payer, John F. Kennedy and Lyndon Johnson ratchet back to single-payer for seniors and poor people, Richard Nixon and Bill Clinton offer national systems that rely on private providers, and now President Obama is building a private system that's initially limited to small businesses and individuals.

There are a lot of reasons for that. One is that political defeat engenders future timidity. But another is that the gaps between proposals give the health-care industry time to grow even larger and more politically powerful, which means that the next president who takes up the issue is faced with a more daunting task and pulls back his ambitions accordingly. If Obama fails this year, then President Chris Hayes, who'll give this a shot in 2030, will be proposing universal health-care for non-avian pets, because who tangles with interests representing 34 percent of the economy?

Photo credit: AP file photo.

By Ezra Klein  |  March 11, 2010; 10:24 AM ET
Categories:  Health Reform  
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Next: The health-care bill is getting more popular


So here, child, finish your nothing, because you'll have even less than nothing tomorrow. What a stirring call to the barricades for the liberal cause, Ezra! Do you come up with these evolving rationalizations of the status quo, or mild incremental reforms, spontaneously or is it the result of study? Inquiring minds want to know!

Posted by: redscott | March 11, 2010 10:58 AM | Report abuse

Wait. I thought according to you private sector employer based health care was in the process of imploding, Ezra. Wouldn't that make it easier for President Hayes (I hope he appoints you to be HHS head btw) rather than harder?

Posted by: redwards95 | March 11, 2010 11:04 AM | Report abuse

I kind of agree with redwards95, in that health care is as much of a bubble in our economy as housing was. It will pop, and it will be just as devastating to our economy. But if the political power of the industry is based on their expansive treasuries, that will, in the long term, be a self-correcting problem.

Not that I advocate for that course of action, but health insurance rates, much like housing prices, can't go up forever. Eventually, they will be collapse back down to earth. The only question is if we bring them down in a controlled manner, leaving a functioning system in the wake, or if we don't and leave chaos and devastation in the wake.

Posted by: burndtdan | March 11, 2010 11:35 AM | Report abuse

If Hayes caves on avian pets he's a damn sellout. I knew I shouldn't have voted for him 20 years from now.

Posted by: dday212 | March 11, 2010 11:46 AM | Report abuse

Pass health care reform now!! Don't let the Obstructionists (Republicans) stop America from doing the right thing by providing health care access to all of its citizens. No socialism claims and other scare tactics will stop us this time from doing the right thing - pass health care reform now!!

Posted by: emmabettyesther | March 11, 2010 4:01 PM | Report abuse

Pass health care reform now!! Don't let the Obstructionists (Republicans) stop America from doing the right thing by providing health care access to all of its citizens. No socialism claims and other scare tactics will stop us this time from doing the right thing - pass health care reform now!!

Posted by: emmabettyesther | March 11, 2010 4:02 PM | Report abuse

IF health care gets to be 34 percent of the US economy, we'll have passed the tipping point of national bankruptcy anyway, as any employer that can will have left the US for China, Canada or Europe in order to avoid the crushing costs, and those that are left won't be able to afford private insurance anyway and we'll be reduced to making morphine available over-the-counter for health reform.

And it will get to be that if we don't reform the system now.

Posted by: dblissmn | March 11, 2010 4:49 PM | Report abuse

We need REAL health care REFORM to improve our health care system and reduce costs. The last thing we need is a Marxist SCAM like Obamacare, which will destroy our health care, our economy, our freedoms and our future.

Posted by: AntonioSosa | March 11, 2010 5:05 PM | Report abuse

Neither Obama nor any other politician can alter the Health Insurance and Health care systems for the better. First they are NOT the same thing. Change has to take place by the Health care providers and the Insurers. While both are being jerked around by the various levels of bureaucrats and politicians nothing helpful will happen.
What ever these folks do will utltimatly only make a bad situation worse.

Posted by: macira | March 11, 2010 10:34 PM | Report abuse

I'll still support president Chris Hayes. At least he'll give health care to someone.

Posted by: metricdisco | March 12, 2010 1:05 AM | Report abuse

There's overwhelming proof that the Democratic Party is now the Democratic Socialist Party and that Obama is a Marxist.

See for yourself:

Posted by: CommieBlaster | March 12, 2010 7:18 AM | Report abuse

And now for a comment that actually addresses the substance of Ezra's post:

Ezra, your thesis that "the history of health-care reform is a history of decreasing ambition" is badly flawed.

First off, the Johnson to Clinton step, (going from a single payer approach for the elderly to a free market approach for everyone) isn't less ambition. It's more ambition, using markets rather than government insurance. The only way government insurance for some is more ambitious than market insurance for all is if you define ambition to require maximum government intervention.

Second, Roosevelt's attempts to reform a minor part of the economy are less ambitious than Obama's attempts to reform a large part of it just by definition. Single payer covering morphine and amputations just must be seen by anyone with an ounce of common sense as being less ambitious than market provision of just about every treatment, procedure, or therapy under the sun.

Posted by: blsdaniel | March 12, 2010 1:08 PM | Report abuse

I think the only thing that Republicans and Democrats who oppose reform have yet to consider is the price of failure to achieve reform. That has a price. Costs and health care availability for Americans.

And a realization by the voters that reform should have passed.

Posted by: KHMJr | March 13, 2010 5:00 PM | Report abuse

Obama and his fellow democrats have used every gimmic in the book to try to get this unpopular horror of a bill passed. They have tried to pass it on christmas eve in the middle of the night knowing full well that it would not stand up to scrutiny in the "light of day". They do not want people to read and understand the actual bill because it is a nightmare!!
Please google "What the Pelosi health-care bill really says" or "What's really in Obama's health care reform bill-a plain english translation" and last but not least "little gems from the health care bill"..

Posted by: joeb123 | March 13, 2010 6:47 PM | Report abuse

Just on the subject of medicare, did you know that with current cutbacks of fees to doctors and hospitals it is already hard to find doctors who will accept new medicare patients? Do you think that by cutting an additional 500 BILLION DOLLARS from medicare it will affect seniors in a positive way? Under "reform" they have reinvented a term "medical home" (section1302) which specifies that patients might have to settle for a "nurse practitioner" rather than a physician as a primary-care provider!
It may be, as I believe, that they expect that you will not be able to find a doctor as a primary care physician at the reimbursement rate they will be paying!
Medicare is going to be severely restricted and rationed. (the medicare fund into which we have all been paying in the form of medicare payrole taxes was systematically looted by congress.)

Posted by: joeb123 | March 13, 2010 6:56 PM | Report abuse

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