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4 Republicans Reject Social and Economic Rights: The Reagan Era and Beyond

4 Republicans Reject Social and Economic Rights: The Reagan Era and Beyond

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HISTORY OF AMERICAN LIBERAL AND CONSERVATIVE HEALTHCARE...



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directly to the states, which allowed for greater state decision making of

how funds would be spent, but generally lowered overall federal allocations for a broad spectrum of social welfare programming.62 The new

government focus was on lowering taxes and cutting government-funded

social programs. Reagan insisted that government spending needed to be

reined in and attacked it, as this was crucial to the moral order and social

imaginary of limited government that he advocated. But the gap between

his rhetoric and policies was substantial. Reagan raised taxes many times,

spent massively on the military, and drove up the deficit.63 Iwan Morgan

explains that Reagan was largely successful in advancing this conservative

agenda: “He pushed through enough of his fiscal agenda to shift public

policy from the liberal course of the New Deal order in the direction of a

new antistatism.”64

These efforts were sometimes accompanied by rhetorical attacks on economically and socially disadvantaged populations, which depicted them as

dependent on the government and exploitative of it. Reagan coined the

derogatory phrase “welfare queen,” which cast a harsh and hateful light

on women on welfare, and many listeners inferred from it that it was an

attack on African-American women in particular. In a speech he made

in 1976 when he was running for office, Reagan introduced the term

and would use it many times when campaigning. “There’s a woman in

Chicago, she has 80 names, 30 addresses, 12 Social Security cards … She’s

got Medicaid, getting food stamps and she is collecting welfare under each

of her names. Her tax-free cash income alone is over $150,000.”65

As elected president, Reagan hammered home the idea that government is intrinsically bureaucratic, wasteful, often cannot be trusted, and is

a threat to liberty. He did this on formal occasions such as his first State

of the Union address, when he stated, outlining his governing ideology:

“Government is not a solution to our problem, government is the problem.”66 And he did it more casually throughout his presidency, creating a

potent anti-statist, anti-government record that often manifested itself less

as a critique than as an ad hominem attack often without nuance or context. Such a characterization of government often lacked specific supporting facts, but had about it an air of snappy truism, making unsubstantiated

claims seem plausible if not downright common knowledge because he

stated them with such confidence and conviction, asserting them without

feeling the need to support them. There were statements of political philosophy such as “I hope we once again have reminded people that man is not

free unless government is limited. There’s a clear cause and effect here that



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is as neat and predictable as the law of physics: As government expands, liberty contracts”67 and “The basis of conservatism is a desire for less government interference or less centralized authority or more individual freedom

and this is a pretty general description also of what libertarianism is.”68

The rhetoric remains largely the same today amongst Republicans,

but ever since the 1994 Contract with America, it has become substantially more extreme.69 Sometimes it is more shrill, sometimes it is carefully

implicit, but with even more dramatic plans for government cutbacks on

social expenditure on programs such as healthcare, housing, education,

and other social programs that were at the heart of Truman’s Fair Deal

and Johnson’s War on Poverty and the Great Society. One exemplar of this

anti-government rhetoric—which represents a significant strand of contemporary Republican ideology—is former vice-presidential candidate Paul

Ryan. Ryan defines liberty primarily in a negative way70 and argues vociferously against federal government programs to address social needs such as

poverty reduction, housing expansion, and increased access to education:

We believe that the government has an important role to create the conditions that promote entrepreneurship, upward mobility, and individual

responsibility. We believe, as our founders did, that “the pursuit of happiness” depends upon individual liberty; and individual liberty requires limited government.71



Ryan attacks Democratic efforts to bring about greater equal opportunity,

inaccurately depicting federal efforts as “centralized solutions” when in

fact many of the programs of the Great Society (some of which are still in

place) were federally funded, but with a great emphasis on local and state

control and implementation and grassroots community development, as

we will see in Chap. 5:

What was once a system of limited government has insidiously evolved into

one with virtually no limits at all. From the New Deal through the Great

Society and beyond, wherever a “national priority” arose—such as housing,

education, or energy—we addressed the problem by centralizing solutions

into new federal bureaucracies which are designed [to] steer and micro manage these priorities in our society.72



Although Ryan acknowledges the importance of “upward mobility,”

he provides no significant policy role for the government in enabling

upward mobility, nor does he provide evidence for how, in the absence of



HISTORY OF AMERICAN LIBERAL AND CONSERVATIVE HEALTHCARE...



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government, such mobility will be enabled. He makes general and unsupported claims about business growth, economic expansion, and charitable and communal support, none of which can provide social goods

such as affordable universal health insurance to all citizens.



2.5



MAJOR HEALTHCARE REFORM POLICY MILESTONES



Although Truman was unable to achieve the passage of legislation for universal health insurance, during his administration, preliminary steps were

made to expand healthcare provision across the nation. In particular, congressional legislation expanded hospital and clinic construction, increasing

access to healthcare substantially across the country. The Hill-Burton Act,

also known as the 1946 Hospital Survey and Construction Act, established a federal program of financial assistance for the modernization and

construction of hospital facilities. The program brought national standards and financing to local hospitals, and raised standards of medical care

throughout the US during the course of the 1950s and 1960s. While

the legislation favored middle-class and wealthy communities because it

required local financial contributions, it channeled federal funds to poor

communities, thus raising hospital standards and equity in access to quality care. The program required hospitals, assisted by federal funding, to

provide emergency treatment to the uninsured and a reasonable volume of

free or reduced-cost care to poor Americans—major policy achievements

with far-reaching effects for the indigent in need of medical care.73

Perhaps the most significant historical moment in the history of healthcare reform, alongside Obama’s Affordable Care Act, was the creation of

Medicare and Medicaid in 1965, under Johnson which made healthcare

affordable and accessible to tens of millions of Americans. Medicare guarantees healthcare to all Americans aged 65 and over and Medicaid provides

healthcare to extremely indigent Americans, providing healthcare to tens

of millions of Americans who would otherwise lack it. However, it excludes

many disadvantaged Americans who, while technically less poor than

Medicaid recipients, are deprived of health insurance because with their

relatively minimal financial resources they cannot afford to buy themselves

health insurance. Many such individuals work full time, earn the minimum

wage, and still struggle to meet their basic needs.74 It also primarily serves

indigent parents of children. Many disadvantaged adults who do not have

children and/or are not disabled receive no Medicaid support.75 Two years

after Medicaid was created, “only 40% of childhood chronic conditions



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were being treated in low income areas”76 and Medicaid has failed to teach

tens of millions of impoverished Americans in need of subsidized or free

medical care, but unable to receive it due to the severe limitations placed

on who qualifies for Medicaid and the parsimonious nature of most states’

Medicaid, which reaches a fraction of the poor who need it.77 As Jonathan

Engel writes:

Medicaid is a flawed program, and has always been … Medicaid has had

systemic problems which have never been wholly corrected. For most of its

history, the program did not reimburse providers at rates competitive with

private insurance and Medicare; it never covered all the nation’s poor; and it

failed to provide consistent standards between the different states’ Medicaid

plans.78



Medicare was influenced by the increasingly universal Canadian system

of health insurance (by the mid-1970s, Canada has established universal

health insurance), but in the US, Medicare exclusively serves seniors. Also

notable in the history of the provision of healthcare in the US is the Indian

Health Service, which provides healthcare provision to Native Americans,

and the Veterans Health Administration, both of which are similar to centralized national healthcare programs such as Britain’s NHS. The creation

of Medicare and Medicaid marked the largest government interventions to

guarantee healthcare to a substantial percentage of the American people.

Several decades later, some states such as Hawaii79 and Massachusetts80

created their own plans to expand health insurance coverage to their most

disadvantaged residents on a near-universal basis.

Another major advance in increasing healthcare provision in the US

to disadvantaged Americans was the creation of the Children’s Health

Insurance Program (CHIP), which provides health insurance for over five

million indigent children across the US. It was recently renewed in 2009

with funding provided until 2013 to continue to enable disadvantaged

children to receive health insurance. CHIP was initiated in 1997 and

has disbursed over $40 billion to fund insurance for uninsured American

children.81 Like Medicaid, it is a state-administered program and every

state has its own guidelines for services and benefits, with wide disparities

amongst states in terms of the effectiveness of their efforts to administer

the program and ensure maximum participation. It has had great success

in expanding insurance, but implementation challenges remain in reaching uninsured children who have the right to insurance but whose parents



HISTORY OF AMERICAN LIBERAL AND CONSERVATIVE HEALTHCARE...



53



are not aware of this opportunity to enroll their children in a free healthcare program, have difficulty doing so, or choose not to initiate the process of enrolling their children in the CHIP program. A total of 25 percent

of Hispanic children, for example, lack coverage.82 CHIP has received the

support of Republicans and Democrats alike and while Republican support has been less enthusiastic and wide-ranging than Democratic support, CHIP remains an unusual example of bipartisan legislation to expand

access to healthcare to the most disadvantaged US citizens.83 Orrin Hatch

and Chuck Grassley, both Republican Senators, played a major role in

initiating and advancing CHIP legislation.

Under Reagan’s presidency, COBRA legislation was passed allowing for

health insurance portability for a period of several years once an individual

has left one job but is still in search of employment, which potentially

increases healthcare security for millions of Americans changing jobs due

to the fluidity of the American labor market, although it does not address

the problem of unduly high costs that many individuals cannot meet. So

twas the Emergency Medical Treatment and Active Medical Labor Act,

which gave individuals “an explicit right to emergency medical treatment

by hospitals that participate in Medicare.”84



2.6

AMERICAN EXCEPTIONALISM: WHY THE US DID

NOT GUARANTEE NEAR-UNIVERSAL HEALTH INSURANCE

UNTIL THE PATIENT PROTECTION AND AFFORDABLE CARE

ACT

There is an extensive literature on why the US remains the only Western

industrialized country to lack universal health insurance and the reasons

provided for this are varied. First, there are structural reasons85 why healthcare reform is always a challenge to pass. While other countries have faced

similar challenges and have succeeded in overcoming these obstacles, in

the US, the power and resources of medical associations and healthcare

corporations, especially large pharmaceutical companies—many of which

are headquartered in the US and earn the bulk of their profits in the US—

are particularly great.86 Furthermore, the structure of the US government

with its system of checks and balances, the large majority needed to break

a filibuster in the Senate,87 and the decentralized powers of the state can

make large-scale reform of federal law extremely difficult to pass because

there are so many opportunities to stall, revise, and reject legislation:88



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The healthcare reform experience under the Clinton administration demonstrates a series of obstacles that make major expansion of government

activity difficult in this sector. Many citizens are skeptical of government

intervention. Interest groups are able to mount public and private lobbying

campaigns on behalf of their preferred policy positions so that reformers find

it difficult to see their vision rise to [the] top of the systemic agenda unchallenged. The federal system dictates that policy can be made (and blocked)

at multiple levels of government … the Clinton health care proposal did

not fail in a Republican-controlled legislature. It failed to get a floor vote in

a session in which the Democratic Party held majorities in both houses.89



What we find throughout the history of attempts at passing universal healthcare is that almost every time a bill to create such a policy is

presented, there is initially strong support for it amongst a majority of

Americans. But this support is quickly eroded when the financial90 and

human resources of corporations—particularly private health insurers and

medical associations, but also at many junctures hospitals and unions as

well—apply themselves to the task of undermining such legislation.91

Doctors have become increasingly supportive or at least tolerant of the

idea of universal health insurance—as reflected in the positive change in

attitude of the AMA, which is now less resistant to universal health insurance than it has ever been before—but only if there are very firm protections

in place enabling them to charge fees with limited government regulation.92 Historically, the fear that racist Southerners had of being forced to

integrate segregated hospitals and clinics also led to support—including

amongst Democrats—to block national healthcare reform efforts which

could force states to desegregate health facilities.93 Indeed, racism played a

large and relatively little-discussed role in the failure of healthcare reform

in the US.  Colin Gordon argues that, in contrast to European welfare

states where welfare programs were seen as provision for overwhelmingly

racially and ethnically homogeneous nations and thus were based on civic

solidarity grounded in shared racial and ethnic identity, there was no such

basis in the US for solidarity amongst citizens:

In the United States, by contrast, deeply racialized contests over citizenship

predate the welfare state and were reflected in it … The U.S. welfare state …

combined deference to labor markets with decentralized administration in

such a way as to exaggerate and perpetuate the racial distinctions inherent in

each. All of this meant not only that African-Americans and Latinos would

remain second-class citizens of the American welfare state, but that many



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