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2 Policy and Discourse of Proponents of Health Insurance Coverage Expansion

2 Policy and Discourse of Proponents of Health Insurance Coverage Expansion

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Truman minced no words by attacking Republicans for impugning the

patriotism of Democrats who supported universal health insurance, deriding their rejection of his policy as mere partisanship rather than a principled policy choice and insisting that the moral issue of equality remained

the fundamental one: a low income should not deprive any American of

his or her health. His final campaign speech when he ran for election after

completing Franklin Delano’s term made the moral argument even more

explicitly, directly linking the Republican refusal to enable universal health

insurance to the premature deaths of American citizens:

Each year more than three hundred and twenty five thousand Americans die,

whose lives could have been saved if they had proper medical care we know

how to provide. This is a greater number of Americans than were killed

throughout World War 2. I have been urging the adoption of a national

system of health insurance so that the heavy medical expenses of the average family could be paid for out of an insurance fund. This is not socialized

medicine. It is plain American common sense!16

This type of confrontational fiery oratory would not return under Clinton

or Obama, neither in its moral clarity and singularity of purpose nor in its

vehemence. Clinton, in calling for healthcare reform in his February 1993

State of the Union address, framed healthcare reform as an economic project, saying: “Reforming health care is essential to reducing the deficit and

expanding investment.”17 He stated:

All of our efforts to strengthen the economy will fail unless we also take this

year—not next year, not five years from now, but this year—bold steps to

reform our healthcare system … Reducing health care costs can liberate literally hundreds of billions of dollars for new investment in growth and jobs

… I will deliver to Congress a comprehensive plan for health care reform

that finally will bring costs under control and provide security to all of our

families, so that no one will be denied the coverage they need, but so that

our economic future will not be compromised either.18

Clinton did not relinquish the moral argument, but he made it part and

parcel of an economic one and his emphasis was primarily on cutting costs

and improving the economy. Obama was reticent about directly criticizing Republicans. He did criticize the healthcare lobby and the insurance

industry, but only very late into his efforts to pass healthcare reform.19 It

was a rhetoric which he used sparingly and with restraint because of his



sometimes strained efforts to project a personal image of transcending

partisan politics and because he presented his healthcare plan as a bipartisan initiative. He would also work closely with the healthcare industry to

win their support for his healthcare reforms and for the individual mandate requiring Americans to acquire health insurance.20


Richard Nixon’s Healthcare Reform Proposal

There is only one Republican President who spoke extensively about

the need for increased access to healthcare and made sustained efforts to

legislate it: Richard Nixon.21 What is notable about the rhetorical strategy he used is its combination of pragmatism and principle, similar in

form to the approach that Clinton and Obama later took. In his 1974

speech to Congress proposing his Comprehensive Health Insurance Plan

(CHIP),22 Nixon frames the importance of expanding healthcare to as

many Americans as possible in relation to the moral and civic imperatives

of American democracy, with particular emphasis on the principle of the

government’s responsibility to ensure equal opportunity for all Americans

to a decent quality of life. He explicitly ties expansion of healthcare to

other progressive social causes, a rhetorical approach which Clinton and

Obama did not adopt, but that would echo Lyndon Baines Johnson’s passage of Medicare alongside other social programs of the War on Poverty

and the Great Society:

One of the most cherished goals of our democracy is to assure every

American equal opportunity to lead a full and productive life. In the last

quarter century, we have made remarkable progress toward that goal, opening the doors to millions of our fellow countrymen who are seeking equal

opportunities in education, jobs, and voting … Without adequate healthcare, no one can make full use of his or her talents and opportunities. It is

thus just as important that economic, racial, and social barriers not stand

in the way of good health care as it is to eliminate those barriers to a good

education and a good job.23

This kind of rhetoric was and is highly exceptional for a Republican, and

has become increasingly so since the Reagan era. Its emphasis on social

justice and outreach to vulnerable sectors of the population, and its integration of healthcare alongside other social causes such as expanding job

opportunity, alleviating poverty, tackling racism, and breaking down legal



and social barriers to full participation on the basis of equality in American

society is all but absent from contemporary Republican rhetoric. Although,

as I have noted, Nixon’s rhetoric reflected in part tremendous pressure to

present a healthcare reform plan because of Edward Kennedy’s efforts to

do so, it remains significant that Nixon was willing to advocate for such a

plan as no Republican president had ever showed such commitment.

Nixon goes on to explain how the high cost of healthcare in the US

is not sustainable, noting that 25 million Americans lack healthcare and

that millions more suffer from lacking coverage which “is balanced, comprehensive, and fully protective.”24 He then analyzes how underinsurance

creates perverse incentives towards higher hospital costs, a lack of adequate preventive care programs, and general waste and inefficiency. After

enumerating these predominantly financial concerns, he illustrates their

devastating human impact:

These gaps in health protection can have tragic consequences. They can

cause people to delay seeking medical attention until it is too late. Then a

medical crisis ensues, followed by huge medical bills—or worse. Delays in

treatment can end in death or lifelong disability.25

Acknowledging these gaps in coverage and their destructive consequences

is absent from most contemporary Republican rhetoric on healthcare

reform. Such rhetoric focuses on cutting taxes and strengthening the private sector, with little attention paid to providing universal and affordable access to healthcare and reducing the waste, administrative costs,

advertising expenditures, and money lost to high profit margins that serve

insurance companies’ economic interests, but raise the costs of healthcare

substantially, price it out of the reach of many Americans, and have no

positive impact on the quality of healthcare.26

Despite these liberal arguments and concerns, Nixon’s plan also shared

both the rhetoric and content of current Republican approaches toward

healthcare reform with their emphasis on the private marketplace as the

main provider of health insurance and on limited government and a small

social safety net for the disadvantaged. However, Nixon’s plan showed

far greater concern with expanding health insurance coverage to tens of

millions of Americans, which no Republican plan discussed as an alternative to Obama’s healthcare reforms provided. Indeed, it is the principle of

near-universality (Nixon’s plan did not have an individual mandate requiring all Americans to be insured, but it would have reached most uninsured



and underinsured Americans) that demonstrates the contrasts between the

willingness of some moderate Republicans to substantially expand health

insurance in the 1970s with the increasing antagonism to such government programs since the Reagan era, when Republicans never agreed to

this principle in large enough numbers to enable comprehensive healthcare reform. Nixon concludes his speech by stating:

The plan that I am proposing today is, I believe, the very best way … But

let us not be led to an extreme program that would place the entire health

care system under the dominion of social planners in Washington. Let us

continue to have doctors who work for their patients, not for the Federal

Government. Let us build upon the strength of the medical system we

have now, not destroy it. Indeed, let us act sensibly. And let us act now—in

1974—to assure all Americans financial access to high quality medical care.27

In his speech, Nixon warns of the dangers of creating a “huge federal

bureaucracy” if the government were to take on too great a role in healthcare provision and insists that private insurers have a central role to play

in healthcare provision.28 Once again, these are statements that are similar in content, if not quite in tone, to those later made by Clinton and

Obama when championing their own healthcare plans. There is a clear and

unmistakable continuity in both the rhetoric and policy content between

Nixon, Clinton, and Obama. But as a prominent Republican advocate of

expanding healthcare access and improving its quality and cost, no other

Republican president or party leader has advanced such a goal so unambiguously and on such a comprehensive scale. Stuart Altman and David

Shactman discuss Nixon’s proposed healthcare reforms, which centered

on an employer mandate to require all employers to offer full-time workers health insurance, subsidized insurance to some poor Americans, and a

benefit package that had deductibles and coinsurance, but with limitations

on these total expenditures. Hospital coverage and total annual doctor’s

visits that were allowed were strictly capped and were not as generous as

many other health insurance plans. Altman and Shactman state:

Although the program had shortcomings, it was comprehensive in scope

and a radical proposal for a conservative, Republican administration. It is

striking to consider how much of its structure and provisions are similar to

plans proposed thirty-five years later. Employer mandates, subsidized insurance for the poor, cost sharing, insurance pools, and catastrophic insurance

have been included in nearly all subsequent plans.29



Thus, while the Clinton and Obama plans went and go substantially

beyond the Nixon plan in terms of their aims and comprehensiveness, it

is noteworthy that many of their core ideas were informed by the Nixon





Emotionally laden discourse rather than fact-centered discourse justified

with evidence has characterized critiques of universal healthcare legislation since their initial, tentative state-based efforts in 1914. Although the

explicitness of such rhetoric has somewhat muted since its more excessive

qualities at the peak of America’s Cold War with the Soviet Union in

the 1950s—when fear of communism reached a zenith and was a major

component of political discourse and campaigning30—the overall tone and

content remain remarkably similar and consistent. The fear of socialism

and the specter of “socialized medicine” (always an imaginary specter and

all the more potent for being so) or of any such similarly worded phrase

became the most powerful and prevalent signifier in healthcare-related

discourse throughout the twentieth and into the twenty-first centuries. It

would be used relentlessly and successfully to thwart attempts to create

universal health insurance by doctor, hospital, and insurance associations

and companies and their political allies.31 The image in conservative rhetoric against healthcare reform of the government as a behemoth potentially

strangling the freedom of Americans as individuals and as owners of businesses remains paramount.

The American Association of Labor Legislation, which initiated the

major federal effort to create universal health insurance for all Americans

in the 1910s, was the first amongst many liberal-minded advocates and

later politicians who failed to register the role of ideology and rhetoric in

the efforts of various sectors of American business, politics, and society to

reject universal healthcare:32

Both in the 1910s and in the 1930s and 1940s, experts and reformers relied

upon rational analyses and arguments about how to solve problems of efficiency or access. Reformers were confident that time was on their side, and

that public health insurance (of one sort or another) would “inevitably” be

enacted in the United States. But each time, not only were there powerful

opponents to reform but debates also quickly took a bitterly ideological



turn. This tactic was not expected by the rationally minded experts and led

to defeats for proposals that might well have gained broad citizen support,

had they been more calmly discussed—or effectively dramatized—in the

national political process.33

While conservatives always proved adept at stoking fears and anxieties that

efforts to create universal health insurance would undermine the quality of

healthcare and limit patient access, liberals never managed to convincingly

articulate how in the absence of reform, Americans would have genuine

cause for fear. The exponential increase in healthcare costs, discrimination against the sick and those with pre-existing conditions that private

insurance companies systematically deny for insurance, and the fact that

by now roughly 50 million Americans are uninsured and tens of millions

of others are underinsured and risk bankruptcy,34 poverty, homelessness,

and family instability as a result are all real threats facing large numbers

of Americans. But these concrete, immediate, and ongoing injustices

have not been as alarming to Americans as the ill-defined and imagined

specter of “socialized medicine.” As Theda Skocpol writes: “Advocates

of health care reforms in the 1990s have more to explain to a sceptical

citizenry about why government can provide desirable solutions to widely

felt problems.”35 As we will see later, this is precisely what Clinton and the

Democrats failed to do in 1993 and 1994, at which time American political and public culture had been saturated with skepticism, hostility, and

outright demonization of the government under the conservative presidencies of Ronald Reagan and George W. Bush.


The False Specter of Socialism

The rhetoric Truman faced in response to his efforts to pass universal

healthcare starkly illuminates the rhetoric of fear and anxiety that have

historically dominated conservative responses to healthcare reform. A

1945 US Chamber of Commerce pamphlet entitled “You and Socialized

Medicine” claimed that the government sought to take “another step

toward further state socialism and the totalitarian welfare state prevailing

in foreign lands.”36 The use of the word “totalitarian” was particularly

excessive and defamatory, an explicit way of creating spurious associations between efforts to create universal healthcare and gross violations

of human rights entailing violence and the absence of due process. The

Chamber attacked Truman’s plan, claiming that it would “lead to the

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