Last updated on July 29, 2004.
This essay appears in The Encyclopedia of the American Democratic and Republican Parties, published by the International Encyclopedia Society. The encyclopedia won the Choice Outstanding Academic Book Award in 1997.
Although federal health care began after the prompting of a Republican senator, the Grand Old Party, increasingly weary of enlarging the central government, soon became opposed to most health legislation. Conservative Republicans of the 20th century have stood almost without exception against federal involvement in health initiatives beyond research, arguing that such programs usurp states' rights and can lead only to socialized medicine. The positions of moderate Republicans have varied by elected politician, with some occasionally proposing or supporting legislation to expand federal health services. Among the Republicans who have significantly battled to thwart health care legislation stands President Dwight D. Eisenhower, who quelled for nearly a decade the gaining momentum of Democrats in Congress fighting for a national insurance act. Republican Senator Reed Smoot of Utah proved himself to be a formidable early opponent of federal health care. On the other hand, a few moderate Republicans, notably Senator Jacob K. Javits and Representative James S. Parker, both of New York, became legislative forces behind an expansion of federal health services.
Federal health care began in 1798 with an Act for Relief of Sick and Disabled Seamen, which created the Marine Hospital Service, the progenitor Public Health Service, the name that the agency took following passage of the Public Health and Marine Service Act of 1902. The bill was enacted after Republican Senator John C. Spooner of Wisconsin for changes in the public health service. But by 1908, the Republican Party's attitude began to show signs of opposition to the public health bureaucracy. The party's platform commended efforts to secure greater efficiency in health agencies and favored legislation toward that end.
Then in 1922 and in 1925, Republican Senator Smoot tried unsuccessfully to combine the Public Health Service with the Veterans' Bureau and to curtail its authority. Smoot's early attempt at consolidation and devolution -- which would be followed by additional and at times more successful Republican attempts at reductions -- was thwarted by Surgeon General Hugh Cumming. But during the 1920s, not all members of the Republican Party sought to curtail federal health care. In 1926, Republican Representative James S. Parker of New York, urged by Surgeon General Cumming, introduced a bill to expand the authority and services of the Public Health Service. In 1928, the Parker Bill passed both houses only to be vetoed by Republican President Calvin Coolidge.
Also in 1926, Democratic Senator Joseph E. Ransdell of Louisiana, the chairman of the Public Health Committee, introduced a bill to create a national institute of health. The proposal, however, languished in Congress for four years, encountering indifference from many members and facing determined opposition from Republican President Calvin Coolidge's Bureau of the Budget. During 1928, Republican Senator Smoot prevented its passage the Ransdell Act's passage.
Yet in 1930, despite the early opposition, both the Parker and Ransdell Acts became law, determining the direction of the Public Health Service for the next 40 years. The Parker Act, officially known as the Public Health Service Amendments of 1930, enhanced the authority and operations of the service. The Ransdell Act was officially known as the National Institute of Health Act. Acting contrary to what would become a general opposition of most elected members of the Republican Party to federal health care, Republican President Herbert Hoover was supportive of the bills, helping to cultivate their chances of passage. Congressional interest in cancer research and crises of influenza and psittacosis also helped propel the bills' passage.
The next big battle over health care came in 1946, when Democratic Senators Lester Hill of Alabama and Harold H. Burton of Ohio introduced a bill to help defray the costs of hospital construction. But the influential Senator Robert A. Taft, an Ohio Republican, frowned upon the bill because, he believed, it allowed for too much federal control. In order to gain his backing, Senator Taft wanted the measure to contain assurances of states rights and local control, money set aside according to state assessments of need, and matching funds for local hospital boards. Hill's measure appealed to many Southern Republican conservatives in Congress because it promised to funnel aid to their states. Even Senator Taft was eventually persuaded to back the bill by a funding formula that awarded the largest sums to the poorest states.
Democratic President Harry S. Truman announced in his state of the Union speech of 1948 that his goal was "to enact a comprehensive insurance system which would remove the money barrier between illness and therapy." For Truman, national health insurance was an issue of equality, and his speech triggered the Democrat-backed drive for a national insurance program. Republicans, however, disagreed with both the need for and the philosophy behind such a program.
In early 1949, President Truman urged Congress to act on medical insurance. Soon thereafter, Democrats presented a proposal to Congress, but it met with strong opposition from Republicans who had formed a coalition with anti-Truman conservative Southern Democrats. They combined forces to successfully block the insurance proposal; it was never reported out of committee. In 1950, '51, and '52, President Truman continued to push for compulsory health insurance. But the prospects for such a bill's passage appeared bleak after 1949, especially when the elections of 1950 increased the Republicans' presence in the House by more than 25 members and nearly allowed them to take control of the Senate.
Despite their crusade against Truman's insurance proposal, many Republicans in Congress were committed to funding the medical research of the federal government. One Republican in particular -- H. Styles Bridges of New Hampshire -- teamed up with several Democrats to gain passage of the National Heart Institute Act in 1948 and the Omnibus Medical Research Act of 1950, which established new institutes for health research.
Through the 1950s and especially after 1955, Congress maintained strong bipartisan support for medical research, resulting in increased funding for the National Institutes of Health in 1957 and 1958.
The 1952 election that installed Republican Dwight D. Eisenhower as president shattered all possibility of a Democrat-supported compulsory insurance bill. In fact, under President Eisenhower, no substantial medical bill had a chance of passage. Even after the Democrat Party regained control of Congress in 1954, they still lacked enough votes to ensure a favorable majority.
The year 1958 rekindled the debate over a national health insurance program. During that year, a member of the House Ways and Means Committee, where at least one earlier proposal for national health insurance had died a quiet death, Aime J. Forand, a Rhode Island Democrat, reintroduced an insurance bill. During the 1950s, statistics began to show that the aged had substantial health and financial problems. But despite the statistics, the Forand Bill soon drew opposition from conservative members of Congress, including many Republicans, who argued that it was regressive and limited. They said it would not offer substantial assistance to those who needed it most while covering those who did not need it. Opponents further argued that Americans are not poor enough to warrant compulsory government health insurance. They added that the bill would encroach on states' rights, a refrain often repeated by Republicans. Although Forand's bill was rejected by the House Ways and Means Committee in 1959 by a 17-8 vote, it did serve to revive the battle over federal health care.
The dawn of the 1960s and the presidential election of Democrat John F. Kennedy, who campaigned on a strong social welfare platform, again put the Republicans on the defensive against federal involvement in health services. In February 1961, true to his party's campaign promises, President Kennedy called for an extension of Social Security benefits to cover hospital and nursing home costs but not surgical expenses for those over 65. Senator Clinton P. Anderson, a New Mexico Democrat who was a high-ranking member of the Finance Committee, and Representative Cecil R. King, a California Democrat who sat on the Ways and Means Committee, introduced the president's proposal as the King-Anderson Bill. The bill, however, did not have bipartisan backing, and Representative Mills, though a Democrat, was determined to consider in the crucial Ways and Means Committee only a proposal that had bipartisan support.
Besides Mills, there were another significant barriers to passage of the King-Anderson Bill. One was the determined opposition of Republicans on the House Ways and Means Committee who had formed a coalition with several conservative Southern Democrats. Together, they formed a strong enough bloc to override the favorable votes of the committee's urban, pro-labor Democrats. In the House, though, the Medicare bill did have the backing of several liberal Republicans.
Yet the aggregation of the negative factors -- opposition from the Ways and Means Committee's Republicans and Southern Democrats, especially Chairman Mills, and President Kennedy's focus on other priorities -- effectively killed the Medicare bill without even a formal committee vote. But the battle for a national program of health insurance was not over yet; it was only postponed. Following the assassination of President Kennedy, the ascendancy of Democrat Lyndon B. Johnson to the presidency brought to the White House a liberal administration committed to social reforms as part of a "War on Poverty." The election of Johnson over Senator Barry Goldwater, a conservative Republican from Arizona, was a turning point for the loss that the Republicans were to suffer on Medicare. Goldwater, a long-time critic of the expanding role of the federal government, had maintained in his campaign that any federal health care programs were a usurpation of states' rights and steps toward socialized medicine, a objection often articulated by conservative Republicans.
Following the 1964 election, the composition of committees was changed to reflect the strength of the parties in the House as a whole. Thus, in 1965, the Ways and Means Committee shifted from 15 Democrats and 10 Republicans to 17 Democrats and 8 Republicans, further ensuring a bloc favorable to Medicare. The fate of the reintroduced King-Anderson bill had changed from being a possibility to a certainty. The bill continued to include coverage of the aged, limited hospitalization and nursing home insurance benefits, and social security financing.
Republicans reacted to the reintroduction of the King-Anderson measure by starting to talk about alternative programs that they saw as more positive. They put forth the following arguments as grounds for opposing the King-Anderson Bill in favor of an alternative: It contained inadequate benefits, with too many exclusions and limits; it was too costly; and it did not distinguish between the poor and wealthy among the aged. To address these concerns, Representative John W. Byrnes of Wisconsin, the ranking Republican on the Ways and Means Committee, proposed a bill for a voluntary insurance system. Byrnes' bill was also driven by the desires of Republicans on the Ways and Means Committee to prevent the Democrats from taking exclusive credit for the health insurance legislation that now seemed to be certainty.
Representative Mills, foreseeing that passage of the King-Anderson Bill was now inevitable, sought to build bipartisan consensus for it. In a brilliant legislative move that at once strengthened the proposal and brought Republican backing to it, Mills moved to draft legislation combining the King-Anderson hospital insurance bill with Byrnes' voluntary plan and an expanded state-administered Kerr-Mills program for all medically needy people. Thus Mills' succeeded in winning bipartisan support for his combination bill because it appealed to the Republicans, many of whom wanted, at most, a voluntary plan.
In 1965, the Social Security Amendments of 1965 passed both houses and were signed into law by President Johnson, establishing Medicare and Medicaid and ending in defeat for the Republican Party a long, bitter fight against national health insurance that began with the Roosevelt administration and spanned the administrations of Presidents Truman and Kennedy and part of Johnson's. Perhaps the most far-reaching health care legislation passed in U.S. history, the amendments included a hospital insurance program for Social Security recipients over 65, funded from payroll taxes, and voluntary medical service insurance for the same group, funding by small premiums and general revenues. It also expanded the Kerr-Mills program for all medically needy people.
The battle of a federal health insurance program, however, did not end with the passage of Medicare and Medicaid. The battle merely shifted -- to what the appropriate level of funding for such programs should be. The origins of Medicare during the 1960s also shaped the dispute over national health insurance in the 1970s, an era during which health policy continued to have strong appeal among Democrats and a few Republicans in Congress.
Among the Republicans, Senator Jacob K. Javits of New York emerged as a strong voice advocating health care legislation. His leadership in Congress, however, was counterbalanced by Republican President Richard M. Nixon's mild antagonism toward federal health programs, an antagonism that manifested itself by calling attention to what he saw as an overburdened health budget. President Nixon tried to better regulate federal health programs and to terminate some of them. In particular, the Nixon administration attacked the Public Health Service as being too independent and too powerful.
In 1971, President Nixon suggested a plan to cut health care costs and to spur development of health maintenance organizations for providing care for Medicare and Medicaid recipients. Although the plan eventually lost favor with the White House, it was embraced by several influential Congressional Republicans, notably Senator Javits and Representative William R. Roy of Kansas. Working with several key Democrats, they adopted Nixon's plan. After three years of legislative effort, the Health Maintenance Organization Act of 1973 created an experimental program to underwrite HMO development, and became a forerunner to the debate over stimulating HMO use during the 1990s.
President Nixon announced in 1972 that he intended to end federal backing for the Hill-Burton Act and several other programs and to cut funding for other programs. He also said he would revoke funds already appropriated to certain health care programs. Congress reacted with anger, securing appropriations for the programs. Congress eventually secured the grant programs at least temporarily in the Special Health Revenue Sharing Act of 1975, passed over Republican President Ford's veto. Many members of Congress, resenting Ford's tactics, backed the health care leaders.
Also in 1972, Senator Wallace F. Bennett, a Utah Republican, introduced the Public Health Service Amendments, which mandating that hospitals receiving federal funds conduct reviews of need.
The late 1970s saw the election of Democrat Jimmy Carter to the presidency and a subsequent respite from the health care debate. During the 1970s, however, many in Congress, particularly Republicans, became increasingly concerned over the rising costs of health care and voiced those concerns during hearings on continuing the programs.
Conservative Republican President Ronald Reagan, soon after his election in 1981, launched an assault on the federal health care system, announcing plans to consolidate all 26 of the health services programs into two block grants, one for health services, the other for preventive health. He also announced plans to slash spending on health by 25 percent. The president's announcement set off a battle in Congress, with conservatives in both parties taking up Reagan's charge. In the Senate, Orrin Hatch, a conservative Republican from Utah, and Phil Gramm, a Texas Republican, led the president's battle to disassemble the federal health care programs. In the House, Republican Representatives Edward R. Madigan of Illinois, James T. Broyhill of North Carolina, and William E. Dannemeyer of California played key leadership roles for the Reagan agenda.
With a few concessions to Democrats, conservative Republicans, backed by many conservative Democrats and moderate Republicans, passed the Omnibus Budget Reconciliation Act of 1981. It reduced funding for all health services programs, collapsed funding for many categorical grant programs into block grants to states, and increased local and state governance over remaining programs. The concessions to congressional Democrats came only after last-minute lobbying by a group of Republican governors.
During the tenure of the Republican Reagan administration, Congress also passed the Tax Equity and Fiscal Responsibility Act of 1982, which tightened regulations on Medicare and Medicaid and established their reimbursement rates.
Also in the early 1980s, President Reagan tried to relax federal rules for nursing homes, but his effort met with bipartisan outcry and eventually led to the passing of a detailed law protecting the rights and stipulating the care of nursing home patients. Republican President George Bush, elected in 1988, continued the Reagan administration's forceful opposition to health programs, often with the backing of many conservative members of Congress.
Running against the general Republican anti-health trend of the 1980s and early 1990s, one Republican congresswoman joined forces with two Democrats to pass the Women's Health and Equity Act. Olympia Snowe, Republican of Maine, worked with Senator Barbara Mikulski, a Maryland Democrat, and Representative Patricia Schroeder, an influential Colorado Democrat, to secure passage of the bill, which created an office for research on women's health at the National Institutes of Health.
The election of Democratic President Bill Clinton returned the health care to the fore of national politics in 1992. Clinton campaigned on a plank of reforming the nation's health care system. True to his promise, he unveiled his proposal in a speech to Congress and the nation on Sept. 22, 1993, saying that Hilary Rodham Clinton had consulted with government leaders of both parties. He proposed a concept first conveyed by Republican President Richard M. Nixon -- that every employer and every individual would be asked to contribute to national health care.
But some conservative Republicans in the House objected to any mandate requiring employers to pay for health insurance. And in general, Republicans argued that the Clinton plan contained excessive controls and would put an undue burden on small businesses to pay for workers' insurance.
Even though Clinton's initiative did reflect several ideas that some Republicans found appealing -- including an attempt to control health care not so much by government directive as by limiting insurance premiums -- the proposal was not alluring enough to survive challenges from the strong Republican minority, led by Republican Bob Dole, the powerful Senate Minority Leader.
In late 1995 and early 1996, Republicans, now in control of Congress, pushed legislation to transform Medicare into a market-driven program in order to help balance the federal budget. Such a program, Republicans argued, would open up the Medicare market to hundreds of private health insurers, giving elderly people a wider variety of plans. Conservative Republican Newt Gingrich of Georgia, the Speaker of the House, played a key role in the highly partisan battle to cut Medicare spending. He won the support of the American Medical Association, a powerful special interest lobbying group, by making concessions to their concerns that the plan would reduce Medicare payments to doctors. President Clinton has threatened to veto Congress' Medicare and Medicaid reform plan, arguing that it would devastate the quality of care for the elderly, especially those in nursing homes.
Republicans in Congress have also promoted proposals to repeal tough federal standards for the quality of nursing home care as part of their general effort to shift power and responsibility from the central government to the states.
Meanwhile, on the local level, elected Republicans have attempted to reform medical care through privatization, with such cities as Los Angeles and New York spinning off city health services. In particular, New York Mayor Rudolph Guiliani, a Republican, has said he wants New York to get out of the hospital business. Arguments for privatization say that the current system is inefficient, delivers poor care, and is unprepared to compete in a managed-care marketplace.
Thus the push and pull over the future of health care policy continues. The nature of the government's involvement in providing health services remains contested ground, as it has since the beginning of the 20th century. And, much as they have throughout the century, the battle lines remain drawn along ideological lines, with a strong coalition of conservative Republicans fighting vigorously against a federal role and a less cohesive group of moderate Republicans taking a more lenient position.
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