1. Why did he try to change? Why was it necessary? One of the reasons why the United States doesn’t have a comprehensive National Health Care Plan is, that the polititcal institutions are structurally biased against reform. That means that in the political era, it’s more important to protect minority factions than majority factions. There are two more interesting questions in the case of health care. First, that in the American culture, individualism and egalitarianism are two of the most important values.
Considering these two ideas it seems to be that there is a contrast in the American policies, because they didn’t prevent from developing a comprehensive, publicly financed education system; so why was the Health Care reform not succesful? The other issue is that in the U. S. the reformers had a well organised and well financed opposition, which could defeat the Health Care plan. How is it possible that in other democracies not? 1. 1. The way toward the reform In the most industrialized countries the political battles about the comprehensive national health insurance were in the first decades of the 20th century.
United States was already in an advantegous position. For example: when in Europe the middle classes were fighting for the right to vote, this right was already granted in the U. S.. But in the case of health care, they didn’t have this advantage. 1. 2. Theodor Roosevelt He tried to protect home life against of sickness, irregular employment and old age through transplantation of a social insurance in an American way. His defeat by Woodrow Wilson and the entrance into World War I are the reasons for the lack of the development in this problem. 1. 3. Franklin Delano Roosevelt First we have to mention, that the U.
S. social system was not so developed like in the European democracies and the executive powers were weak too. The President promoted progressive social reforms, but despite of his popularity he and his advisors came to believe that to put health insurance plan into the reform package would defeat the whole bill. This was a strategic choice, because they knew that the Congress writes law and that the hospital and insurance industries, with powerful American Medical Association would attack the entire New Deal. Enormous political power belonged to economic interest groups and entreched local elites, so Franklin D.
Roosevelt thought that to put the health insurance into the Economic Security Act would have been impossible. 1. 4. Harry S. Truman He strongly supported the health care reform from the beginning of his presidency. His concept was that one of the most important part of a nations strenght is in the health of his citizens, to participate in a democracy needs good phisically position. A big public support surrounded the plan, about 74,3 % of American favoured national health insurance. It was assumed that they will continue this regulation after War too.
It was necessary to sustain economic growth and fight against post war depression. The work on the health insurance was delayed by other political consideration, but this was a fatal idea. The American people had the impression that Truman was an inefficient president. To show their opinion they sent a Republican Congress to Washington in 1946. After this alarm President Truman started to change. In 1947 Senator Robert Taft tried to challenge Democrats to put the health care insurance into the campaigne plan. That was unfortunately for Taft and for the Republicans, because the plan backfired.
Truman made the health care to the cornerstone of his campaigne. He attacked Republicans on their weakest point: „We worked out a painstaking plan for national medical care… It provided for new hospitals, clinics, health centers, research and a system of national health insurance. Who killed it? The Republicans 80th ’do-nothing Congress’”. Truman’s strategy was succesful, he not only won the election; the American citizens elected a Congress, where Democrats got 75 more seats than Republicans. 82% of the American population agreed that the goverment should make the access to medical care easier.
Now we know that Truman did not bring about national health care insurance. The reason for it was the ’Committee government’ which allowed the Congress to protect itself against the growing powers of goverment executive. The Truman health bill could not find enough support, votes to report the bill out of the Senate Finance Committee. Finally but not at last, Republicans and Southern Democrats tried to promote their own version of a health bill. There was of course no real chance for a conservative health care program, but the voter could be persuade that the Congress was working on a better plan than the Truman.
In the end, no effective advance was made towards enacting the national health insurance in 1949. After this Americans got frustrated with the Democrats, because they raised public expectations and did not fulfil their promises. After the defeat of his plan Truman turned his attention for the foreign policy crises, because that was an arena where the President has a high degree of authority and power. Their unabiltity to execute their promises undermined the public confidence in the president and presidency. The result of this was that Eisenhower won the electoral battle.
After this the universal coverage reform was an impossibility, but they started to work on a ’get a foot in the door’ plan. That meant a hospitalization coverage for the aged. The ground of this aim was the Social Security system, introduced by Franklin D. Roosevelt. They wanted to offer aged protection against financial bankruptcy due to illness and to expand this coverage to larger parts of the American community. This plan was two in one; it did something good and began to legitimate the state’s involvement in the health care sector. This bill was presented every year, but was never discussed until 1958.
Therefore reformers find the excellence of taking half a loaf and fighting for the other half later. 1. 5. Medicare The Medicare system come into existence during the presidency of Lyndon B. Johnson. Chairman Mills made a suggestion which fundamentally changed the structure of the Medicare program. Mills asked whether they could combine the insurance for aged with a voluntary program of insurance (that was similar to a Republican proposal which include for physicians fees). Further he asked for a plan which covers the health care expenditures of poor people, who were not contained in the Medicare motion (it’s called Medicaid).
We have to mention that Mr. Mills changes „built a fence” around the social security program. In general Medicaid was the continuation of the past. 1. 6. The Medicare Legacy It’s not a surprise that the Medicare/Medicaid system was instrumental in the financing problems of the health care in todays United States. The Medicare/caid program opened a spigot where money flows from the goverment to the medical industry. The result of Medicare/caid also included public funding health care industry and a protection against a comprehensive national health insurance plan.
In 1973 Senator Russel Long, Chairman of the Senate Finance Committee and Senator Abraham Ribbicoff introduced a health reform bill which would offer protection from losses due to catastrophic illness and would give a new structure for the administration of the Medicaid program. This cathastrophic plan motivated Senator Edward Kennedy, who was desperate to get a plan that had universal coverage. At the end of 1973 Nixon tried to reorganise his position, because after the Watergate scandal he needed to refocus public attention and legitimize the office of the Presidency. The national health insurance was the key for his comeback.
Both, Kennedy and Nixon were ready to deal on natioal health care. At the end Kennedy and Mills came together to work on a compromise plan. That was a big step in closing the distance between Republican and Democratic proposals. 1. 7. Problems in the work Now we know that the bill passed, but we have to speak about few problems. First of all we have to mention the labor groups, which were always loyally represented by Kennedy, decided not to support his compromise plan with Mills. The another lack of support came from Russel B. Long in the Senate. He promoted his own concept of the national health insurance. 1.
8. Carter After the election in 1976, it became obvious that large proportion of the American public were being left out of the medical care system. Everybody knew that after the defeat of Gerald Ford the major health care reform was just on the corner. Unfortunately at that time the Congressional reformers passed which made health care reforms „less and not more likely”. According to this institutional context and the growing fiscal pressure led to a two-stage political strategy. They decide first to push a cost-control legislation through the Congress and than to expand the project to a more comprehensive one.
First, they wanted to get a control over the increasing medical costs by the hospitals, because the cost of the hospitals overtook other ares in the medical care. Secondly Carter got the advise to „divide and conquer” rather than to focus on the whole health care industry. Medical lobby protest against the plan, because they had a feel that there is more behind the first step. The legislation took back his assistance, because the Chairman of the Senate Finance Committee disliked the short term objectives of Carter, instead of this he preferred hos own, long term plan, which protected the Medicare system.
In the new post-reform Congress, a bill required consensus from all the four Chairmen. Each of them proceeded in it’s own direction. That’s one of the reasons why President Carter was never able to collect the necessary votes to get the plan out of the Committee. Carter couldn’t pass any sort of cost-containment legislation, and that killed the chance to be succesfully in the national health insurance. His plan was introduced in 1979, but noone took it seriously. It’s more than interesting that the public opinion was till the end of 1979 really strong in the question of comprehensive health care.
The defeat of President Carter again shows us that the national institutions are unable to handle with those problems they brought to the inhabitant’s attention. The trust and faith in these institutions collapsed and more than 60% of the American citizens thought that the goverment was incapable to do what was right most of the time. According to Theodor Marmor in the 1970’s the U. S. and Canada spent the same, about 7% of the GDP on the health care. After 35 years this number increased, enormous in America; they spent 50% more than their North neighbours.
These costs shows us, that how huge are the problems in the medical care of the United States. We have to mention that the history of American medical care from the 1970’s till today is full with conflicts and changes but without solution. In the 1980’s it seemed to start a change; prominent political figures started to promote goverment-financed universal health insurance, either for the nation or for the state. The deficits of the Reagen and Bush governance were in the spotlight. That’s why the reformers wanted to rationalize medical care provision through bureaucratic realiguments.
The financing concept was for example: diagnostic-related group payments to hospitals (DRG’s). When this plan failed, the reformers find another way through competition and privatization. The ideology behind this was the market competition. In the background of the major changes were private initiatives. In the world of health care or hospitals, small chains of for-profit hospitals (like the Humanas and Hospital Corporations of America) grew into large comapnies. HMO’s (Health Maintenance Organizations) were rapidly dominated by for-profit firms.
These above-mentioned deeply rooted problems and mistakes led to Bill Clinton’s attempt, to make a new health care plan 2. The Health Care Plan 2. 1. Contemporary problems Most of the Americans have a private health insurance, and it’s important to notice that 20% of the citizens are covered by targeted public plans (Medicare/caid). The most shocking data is that more than 46 million Americans are without health insurance. Even if the emergency care is legally available to all, medical bills are the 2nd major cause of personal bankruptcy.
To access the system is worser and worser, the list of uninsured and under-insured is always growning. In most of the cases the insurance comapnies try to reduce the coverage. Money for health care in GNP: 1970| 1980| 1990| 2008| 7%| 8%| 11%| 16%| Despite of the high costs the life expectancy of teh U. S. citizens is the same that in Cuba. The biggest problems of the system are the high administrative costs, the less preventive care, the ’pre-existing conditions’ and that sometimes treatments are cancelled because they are concidered ’experimental’.
Generally we can say that Americans spend the most and feel the worst about their value for money. We have to notice that there is no common politics of American medicine. There are existing politics in the nation’s medical care, but no politics of American medical care. 2. 2. The plan First we have to shortly summarize the economic situation. The federal debt reached record levels under Reagen administration policies. The health care costs increased rapidly through this period. Even the business sector found it necessary to act, because the health care sector used 12% of the nation’s GDP in 1990.
The gap between the lower and upper classes grew which meant finacial insecurity. In the 1990’s the Americans were affraid about loosing their health benefits and not being able to pay their medical bills anymore. A wide range of proposals turned out for instance: market-oriented reforms expanding the private system, public single-payer plans, employer mandates (play-or-pay). The so called „managed competition” was favored by Bill Clinton. The 1993 health care plan is often called „HillaryCare”, because the President Clinton assigned the First Lady to lead the reform. 2. 3. Elements of the plan.
Clinton’s plan the Health Security Act was about a universal coverage, employer and individual mandates, competition between private insurer and was to be regulated by the goverment to control the costs. That means that the private insurers under managed competition would compete for business groups and individuals. That was called „health-purchasing alliances”. Every American citizen would have ’health security card’. The core element of that, was an enforced mandate for employers, which meant health insurance (coverage) to all their employers through competitive (but regulated) health maintenance organizations.
Clinton delievered a health care speech on September 22. 1993. He explained the problem following: „Millions of Americans are just a pink slip away from losing their health insurance, and one serious illness away from losing all their savings. Millions more are locked into the jobs they have now just because they or someone in their family has once been sick and they have what is called the preexisting condition. And on any given day, over 37 million Americans—most of them working people and their little children—have no health insurance at all.
And in spite of all this, our medical bills are growing at over twice the rate of inflation, and the United States spends over a third more of its income on health care than any other nation on Earth. ” A the time of the speech nearly 6 from 10 Americans said that they supported Clinton’s plan. This number included the majority of the Democrats, adult from all age group and education and middle-income Americans. Just the Republicans and those persons were opposed to it who earned more than $ 50. 000 per year. The big turn came in April 1994. President Clinton lost his majority support.
That means that the middle-income Americans (those who earn between $20. 000 and $ 49. 000 per year) political Independents and adults over 30 turned away from him. The biggest decline was among those who were over 65 (from 62% in September 1993 to 37% in April 1994). Just the Democrats and the poor continued to support the plan. 3. Criticism and defeat In my study I want to give two approaches about Clinton’s defeat We have to say that President Clinton invested a lot of legislative energy in the health care reform, because he really belived that it will be succesful. 3. 1. „Learning from defeat”.
Major social reforms do not pass except war or depression. Just the strongest President is able to push a reform like this through the Congress for example: during economic collapse, wartime or a tragedy. The political scientist Cathie Jo Martin said: „American social policy seems to have reached a dead end: there has no real innovation since the 1960’s”. It was naturally that the reform had no succes in 1994-94. The biggest problem was that the American medical care started to become an econimic role. According to Henry Aanron we have to recognise that the health care became the 7th economy in the U. S..
Even President Clinton was not able to renew the medical care from top to bottom. It got criticized because in some parts it relied on the private health insurance and the employment-based system of medical care financing. More important that the comprehensive medical care showed similarities with those fundamental acts, which had seen to be untouchable. In retrospect the wars in the U. S. history always raised the public refusal against social reformers, that helped with this their conservative enemies, for example: The War in Vietnam ended Lyndon Johnsons Great Society, the Korean War destroyed the last remains from Truman’s Fair Deal.
3. 2. „Only Instrumental reform plan could have passed” One of the biggest mistakes from Clinton was that they used an ’all-or-nothing’ conception instead of an incremental reform plan. Allen Schick summed this:”Incremental demands are more passable than comprehensive demands”. On the other hand we have to tell that there are many good reasons to prefer a comprehensive way. First of all there is the risk, is we solve just the most urgent problems the boarder problems could be forgotten. That was one of the argument of the reform supporters; an incremental help would not solve the plight of the uninsured and underinsured.
Admittedly, incremental reforms may not yield enough benefits to make them worth. For instance Tax reform was impossible till the Congress took a comprehensive approach in the Tax Reform Act of 1986. That made the political and economical benefit worth the inevitable pain. This has to do something with that they want avoid blame. Finally, the comprehensive reforms have significant adavantages whereas the incremental reforms have serious technical mistakes. For example: having all citizens in the same system reduces the administrative costs and it’s easier to focus on total societal outlays.
Small reforms often have unintended consequences. Large changes in public policy are rarely, but those rare moments are important for the direction of public policy and for the lives of Americans as well. 3. 3 . „Only bipartisan reforms are enacted” According to Schick we can say that the major reforms need bipartisan support. So another blunder in President Clinton’s strategy was that he tried to lock out Republicans, or to ignore congressional moderates, who submitted a compromise solution. He just wanted to win liberal Democrats to his proposal. Especially in two-party systems the bipartisan support is indispensable.
Medicare is a good example for the ’copartisanship’, that means Republicans and Democrats worked separated on proposals, but they were combined after the 1964 elections. A cooperation like this may would have helped President Clinton’s aim, but they hoped that public support would be enough to jump over party lines. 3. 4. „There is no prospect for major health care reforms in contemporay American politics” People who believed in 1993 that the health care reform was close to be true, now see that it was wrong from the beginning. It’s normal that the people were first optimistic and after the defeat saw the question very pessimistic.
But we can say that the health care reform is an issue that will not disappear from U. S. politics. Now the people are not open for a reform, but we can still feel the heritage of Clinton’s failures. 3. 5. Lesson from history and historical comaprison History is a good teacher and with the help of it, we can see problems, failures in a complex way. To learn from the past needs a comparison between past and present or past and some future state. For example: we can follow how the goals changed in the health care reform during the time. First in the Progressive Era they wanted to save workers from the drops in income what can follow sickness.
In the 1940’s they wanted to give all Americans access of American medicine. And in the 1990’s they wanted to reduce the medical cost and to make health insurance coverage universal. These movements led to the comprhensive health care reform, which is an important part of Barack Obama’s political concept. With the election of Bill Clinton the people got again a hope for a comprehensive natioanl health insurance. There were numberless reasons to wait for the reform and to predict it’s succes. For example: the corporate sector showed a concent for the fundamental reform.
Over 30 million Americans were without health insurance and tens of million had a fear to loose their insurance, therefore even the middle class felt the time ready for a reform. Bill Clinton used the national health insurance for keystones in his electoral campaignes. It seemed that everyone understood that the changes were not just only politically necessary, but also morally and economically. 3. 6. So what happened? According to James Madison the ground problems were the Progressive reforms which undermined strong political parties and the congressional reforms broke the political power.
First we have to mention that the political institutions are not the same like 30, 40 years ago. The oligarchy became into a decentralized institution and the Congress got more permeable and less manageable. Secondly the health care is 1/7th of the U. S. economy so there are a large number of interests who have to loose something important with a comprehensive health care. Third it’s important to notice that Clinton’s bell needed more than 50 % support of the members of the House and 50% of the Senate. But a congressional rule allowed a minority to block the legislation as they could have just 40 out 100 votes in the Senate.
There is no other democratic system who needs 60% support from the legislators to pass goverment plan. Fourth, in the 1990’s was the public support the highest in the question of goverment intervention in health care financing. But the American taxpayers had to handle with an incredibly debt, so that’s why the government was unlikely to finance the reform. Fifth, Congressmen and women became independent which means money. Between 1993 and 1994 the candidates from the House and the Senate got $38 million for their campaign from the health insurance industries. And the last we have to notice the role of the media.
That was the most important change in the modern politics; for example: The American Hospital Association spent $14 million on the ’Harry and Louise’ advertisement. These above enumerated issues are part of the defeat of Bill Clinton’s plan. 3. 7. The American attitudes towards the health care In 1994 only 19 % of inhabitants said that just minor changes were enough and 48% concur with this statement: „Our health care system has so much wrong with it, that we need to completely rebuild it. ” Americans distrust in the goverment is also because they were unable to accomplish a comprehensive social reform.
That doesn’t mean that the American citizens want to have more goverment intervention in their life. It’s just absurd that families could be destroyed when someone gets ill because the country didn’t insure them. The opponents of the reform were really careful they did not argue against the plan, they just mentioned that it would be the same like the other reforms. Clinton and his advisors lost the public relations fight, but this is not a surprise, when we take into accoutn that the anti-reformers spent more than $300 million on lobbying and adevrtising against President Clinton’s health care bill.
The emotional images in the 1990’s was not only the Socialism presence, but the new boogey man was the goverment itself. The Americans had a fear that the goverment would create a new inefficient bureaucracy. 4. Health Care after Clinton In 2004 Hillary Clinton (U. S. Senator from New York) attempted again. She offered several solutions, because the health care system was unsustainable. In 2005 referring to her previous efforts Hillary Clinton said: „ I learned some valuable lessons about the legislative process, the importance of bipartisan cooperation and the wisdom of taking small steps to get a big job done.
” And in 2007 she rethought her role in 1993-1994: „I think that both the process and the plan were flawed. We were trying to do something that was very hard to do, and we made a lot of mistakes. ” Interesting to mention, that Hillary Clinton received hundreds of thousands of dollars for her campaigne for the reelection in 2006. The money came from doctors, hospitals, drug companies and from insurance companies which are members of the Health Insurance Association of America. If we can remember HIAA was one of the organisations who helped to defeat the Clinotn health plan in 1994.
The Clinton health care plan was the most prominent natioanl proposal; and it may had benefits for Hillary Clinton on the 2008 presidental election. In 2007 Paul Starr (former Admisnistration senior health policy advisor) published an artical (’The HillaryCare Mythodology’), where he declared that Bill Clinton, not Hillary Clinton was the driving force behind the plan, and after Hillary took the lead, the plan quickly became useless. After the look into the development of the American health care system, we can acknowledge that the Clintons didn’t have an easy way.
They couldn’t deal with this bitter political heritage. In this market-oriented medical care, where the money dominates instead of the people’s life, was hard to fight for changes. However the election in 2008, gave a new opportunity for the changes in the person of Barack Obama. Barack Obama’s health care proposal included the expansion of health insurance coverage, that means to cover the uninsured. His motion would spend $ 900 billion over 10 years and contains a goverment health insurance plan to compete with the private sector.
It would be forbidden for the insurers to drop sick people or deny them the coverage, because of pre-existing conditions and demand every American health covergage. His proposal also includes control over medical spending and taxes on insurance companies that offer expensive plans. Obama supported a public health insurance option; this would lower the costs and improve quality. The 1017 page plan was introduced on July 14. 2009. On December 20. 2009. a version of the bill was passed in the Senate on a party-line vote of 60-39.
Bibliography * Learning from Defeat?
Political Analysis and the Failure of Health Care Reform in the United States JACOB S. HACKER * WHAT HAPPENED TO AMERICANS’ SUPPORT FOR THE CLINTON HEALTH PLAN? by Robert J. Blendon, Mollyann Brodie, and John Benson * National Health In surance—A Brief History of Reform Efforts in the U. S. -The Henry J. Kaiser Family Foundation * One Issue, Two Voices- The Canada Institute * Its the Institutions, Stupid! Why Comprehensive National Health Insurance Fails in America-Sven Steinmo and Jon Watts-University of Colorado at Boulder.
[ 2 ]. From Address at Gilmour Stadium.. Sept. 1948 (Its the Institutions, Stupid! Why Comprehensive National Health Insurance Fails in America-Sven Steinmo and Jon Watts-University of Colorado at Boulder) [ 3 ]. Its the Institutions, Stupid! Why Comprehensive National Health Insurance Fails in America-Sven Steinmo and Jon Watts-University of Colorado at Boulder) [ 4 ]. Its the Institutions, Stupid! Why Comprehensive National Health Insurance Fails in America-Sven Steinmo and Jon Watts-University of Colorado at Boulder) [ 5 ]. Its the Institutions, Stupid!
Why Comprehensive National Health Insurance Fails in America-Sven Steinmo and Jon Watts-University of Colorado at Boulder) [ 6 ]. National Health In surance—A Brief History of Reform Efforts in the U. S. (The Henry J. Kaiser Family Foundation) [ 7 ]. Learning from Defeat? Political Analysis and the Failure of Health Care Reform in the United States JACOB S. HACKER [ 8 ]. Learning from Defeat? Political Analysis and the Failure of Health Care Reform in the United States JACOB S. HACKER [ 9 ]. Learning from Defeat? Political Analysis and the Failure of Health Care Reform in the United States JACOB S.
HACKER [ 10 ]. Learning from Defeat? Political Analysis and the Failure of Health Care Reform in the United States JACOB S. HACKER [ 11 ]. Learning from Defeat? Political Analysis and the Failure of Health Care Reform in the United States JACOB S. HACKER [ 12 ]. Learning from Defeat? Political Analysis and the Failure of Health Care Reform in the United States JACOB S. HACKER [ 13 ]. Roper: June 28, 1994 (Its the Institutions, Stupid! Why Comprehensive National Health Insurance Fails in America-Sven Steinmo and Jon Watts-University of Colorado at Boulder).