Health Reform's "Red" Herring

As Congress returns from a summer recess of heated town hall protests and even hotter political rhetoric, health reform is on the ropes. An NBC News poll tells the tale – 54% of the public are more concerned that the government will go too far with reform and make quality worse than are concerned that government will not do enough. In April, a quarter of Americans thought that President Obama’s reform plan was a bad idea while one-third considered it to be a good idea. Today, roughly a third still considers it to be a good idea, but fully 42% now think it is a bad idea. According to Gallup, President Obama's approval rating has fallen farther and faster than nearly all presidents since Harry Truman. This is a key measure as studies have demonstrated that a President’s legislative success is more influenced by his standing with the public than by whether his party controls Congress.

President Obama, his surrogates, and Congressional allies attribute this decline in public confidence to “misinformation” and “scare tactics” employed by organized interests intent on derailing reform. Town hall protesters and numerous conservative critics have attacked Congressional reform proposals as “socialism” and even compared them to National Socialism under Nazi Germany. Another protester accused House Majority Leader Steny Hoyer and Speaker Nancy Pelosi of aiding the President in “spiraling us rapidly toward socialism.” When a protester in Massachusetts asked Rep. Barney Frank how he could support “Nazi policies,” Frank simply dismissed her with a joke. But such a line of attack is no joke. Rather than demonstrating a preparedness for such attacks, the White House and Congressional leaders have reacted to these criticisms in a disorganized and poorly coordinated effort and the lack of any coherent response allowed critics to undermine public confidence in reform. As a professor of American politics and a health policy scholar, I cannot help but ask how the White House and Congress were caught so unprepared for this fight.

Look at the lessons of history: When President Franklin Roosevelt was considering the inclusion of national health insurance as part of the New Deal, American Medical Association (AMA) president Dr. Morris Fishbein denounced even plans to promote voluntary private insurance as “socialism and communism.” In 1948, the Federal Security Agency (precursor to the Department of Health and Human Services) issued “The Nation’s Health: A Report to the President” which determined that only national health insurance could effectively organize the American health care system and create a stable financial basis for funding health care. Republican critics in Congress attacked the goals of the report in eerily familiar terms. “Wherever some form of dictatorship prevails in government, there we also find some manifestation of socialized medicine… Communism, Fascism, Nazism, Socialism – all are alike in that they enforce a system of State Medicine.” When President Truman introduced national health insurance legislation in 1948, the AMA hired a public relations firm to derail the plan. The objective - keep public opinion hostile to reform. Clem Whitaker, owner of the firm hired by the AMA, made the strategy clear: “All you have to do is give it [reform] a bad name… America is opposed to socialism so we’re going to name national health insurance “socialized medicine.” The U.S. Chamber of Commerce published a report titled “You and Socialized Medicine” warning that any form of compulsory health insurance served the Democrat’s plan to impose socialism and totalitarianism. Three-quarters of the American public supported national health insurance in 1945; by the end of 1949 less than one-quarter supported such reforms. Truman lamented how critics had “distorted and misrepresented” his proposal. Sound familiar? Truman attempted to salvage his reforms, but the die had been cast.

In the decades since, all significant proposals for health care reform have been met with counter offensives by some combination of interest groups. The players have changed, but their strategy has rarely wavered – any manner of significant health reform is labeled “socialism.”

Even when reformers sought to minimize the government’s role in any reform, the line of attack remained. When President Eisenhower endorsed publicly financed catastrophic insurance, in an effort to protect the private insurance industry, the AMA denounced this modest reform as socialism. So effective has the “socialism” strategy been, that every serious health reform proposal since the 1970s has been premised upon a reliance on the private health insurance market. Even the late Senator Ted Kennedy, one of the nation’s staunchest advocates for universal health insurance, abandoned a single payer, Medicare-like approach, in the late 1970s. From 1979 through to the current debate, Kennedy advocated reform based on the private market. In 1993, President Bill Clinton’s Health Security Act sought to achieve universal coverage via a combination of individual and employer mandates. In a conscious effort to avoid government financed reform it relied almost exclusively on private insurers – yet it was almost immediately denounced as socialism, or "creeping socialism."

Of the current reform proposals being given serious consideration in the House and Senate none advocate socialized medicine. In fact, for good or for ill, all enhance the role of private insurers and our current employer-based approach to insurance delivery. Yet, the socialized medicine and “Nazi policy” critiques have reached a fever pitch. Reform proponents have largely dismissed such protests as the rhetoric of an uninformed fringe movement. But those who dismiss this line of attack ignore a key lesson from past health reform battles – the strategy works and should be taken seriously. Fears of “death panels” or rationing can all be linked to the images of compassionless or dispassionate care evoked by raising the specter of socialism or Nazism

Given its potency, reform proponents must defuse the power of the socialized medicine label. One approach could be pointing out that when it came to ensuring that our veterans receive the high quality care they deserve we opted for socialized medicine in the form of the Veterans’ Health Administration (VHA). The VHA represents socialized medicine in its purest form, government ownership of the facilities and employment of the providers. Proponents might remind voters that to guarantee access to health care for our seniors we adopted quasi-socialized, or single-payer, medicine in the form of Medicare. Seniors receive care from private hospitals and physicians, but they are insured by the federal government. Both programs consistently receive higher customer satisfaction ratings than do private insurers and do a better job of controlling costs while ensuring access to care - hardly indicative of compassionless “socialized medicine.” It’s no coincidence that some of the most vocal town hall protesters are seniors fearful that reform would undermine the Medicare coverage they treasure.

Every major defeat of health care reform has been followed by roughly 15 years of inaction or only minor reforms. That’s 15 years we cannot afford to lose. With 47 million uninsured, millions more under-insured, and with rising health care costs threatening our long term financial security, we must reform our health care system. A recent study by the Commonwealth Fund determined that America trails the UK, Australia, Canada, Germany and New Zealand with regard to quality, access, efficiency, equity and healthy living. If this effort does fail, it will not be because opponents found a new means to stifle reform. It will be because the President and his allies were caught unprepared to counter a line of attack that is now old enough to qualify for Medicare. Historians and political scientists will be left to wonder how they failed to prepare for this fight.