Considering History: Health Care Is a Founding American Ideal

A number of prominent news stories this week have brought health insurance back to the center of the conversation. Two distinct but parallel documents went viral: Anthem Blue Cross Blue Shield’s plan to put time limits on the amount of anesthesia they would cover (a plan they reversed after receiving extensive backlash); and a (potentially fabricated but deeply revealing) doctor’s letter to United Healthcare about their failure to cover children’s chemotherapy medications. And speaking of United Healthcare, the company’s CEO Brian Thompson was murdered in New York City on December 4^th, a violent act that seems to have been undertaken in direct response to the company’s denials of insurance claims.

Murder and other violent crimes are never an answer to social or political problems, and indeed create far more problems than they could ever solve. But the public response to Thompson’s death, like the conversations around those viral documents, reveals our widespread collective frustration at the failures of the health insurance industry to help people receive the medical care they need. As revealed in foundational American histories and cemented in law by a series of vital 1960s programs, health insurance and health care are essential to our Constitutional ideal of “promoting the general welfare.”

One of the earliest American communities, the Massachusetts Puritans, established an elaborate and longstanding system through which health care and other essentials for the community’s poorest residents were a collective, public responsibility. Governor John Winthrop had called for such programs in his December 1630 sermon “A Model of Christian Charity,” a manifesto for this new community’s ideals and mission, and the Massachusetts Bay Colony he helped lead responded to that call by creating the Boston Overseers of the Poor. From the 17^th century through long after the American Revolution, this civic organization and others modeled on it across the region provided relief to those in need in the form of money, food, fuel, and medicine.

While cities and other local communities frequently took the lead in such relief efforts, the framers of the new federal government also recognized that such collective responsibility likewise existed on the national level. In the Preamble to the Constitution, “promote the general Welfare” is one of the handful of goals expressly delineated for that document, the government it created, and the “more perfect Union” it envisioned. And a decade later, during Constitutional framer John Adams’s term as President, he signed the first law establishing federally supported and mandated health insurance: “An Act for the relief of sick and disabled Seamen” (1798), a law that required a portion of all seamen’s wages to be deducted in order to fund medical care and hospitals for their sick and disabled colleagues.

Other Founding Fathers also expressed their support for collective health insurance and care as American ideals. During his presidency, in response to smallpox epidemics and debates over vaccinations, Thomas Jefferson wrote that “I think it is important … to bring the practice of the inoculation to the level of common capacities, for to give this discovery the whole of value, we should enable the great mass of the people to practice it on their own families and without an expense, which they cannot meet.” And a decade later, after signing into law the Vaccine Act of 1813, which among other details required the postal service to ship vaccines free of charge, James Madison created a federal vaccine institute that offered this vital medical care to all Americans at no cost.

These foundational laws targeted specific communities (like seamen) and health emergencies (like smallpox epidemics), but I and many other scholars would argue that the Constitutional concept of “promoting the general welfare” goes far beyond such contexts, and includes a recognition that health insurance and care must be rights guaranteed to all Americans if that collective welfare is truly to be promoted. Those ideas began to take broader hold with the Progressive movement in the late 19^th and early 20^th century, and truly came to fruition as an integral part of a series of interconnected federal laws that will celebrate their 60^th anniversary this coming January: the Great Society.

The Great Society laws put forward by President Lyndon Johnson and his Congressional allies covered a wide range of issues, from Civil Rights to immigration, education to housing, and more. But no Great Society law was more influential in reshaping and expanding the federal government’s programs and promotion of the general welfare than the Medicare and Medicaid Act of 1965. That law was also known as the Social Security Amendments of 1965, and Medicare in particular did build directly on Social Security (enacted in 1935), extending that groundbreaking program’s social safety net for seniors to include health insurance. The Act continued Social Security’s longstanding emphasis on protecting older Americans but made it far clearer that health insurance and care were crucial elements of that governmental, collective effort.

The other new program created by this 1965 law, Medicaid, was even more innovative and important still. Part of the Great Society’s overarching goal of a “War on Poverty,” Medicaid was a community-focused health insurance program, one designed to guarantee a baseline level of health insurance and care for even the most disadvantaged Americans. It soon evolved to feature even more groundbreaking initiatives like the Children’s Health Insurance Program (CHIP), offering access not only to health insurance but also to community health centers for all American children and families. Medicaid has continued to evolve and grow over the decades, with new programs like coverage for incarcerated individuals truly reflecting a goal of promoting the general welfare through health insurance as a shared American ideal.

One of the 21^st century’s most influential federal laws, the Patient Protection and Affordable Care Act of 2010, extended those guarantees of health insurance and care to even more Americans. But as the recent viral stories have reflected all too clearly, private health insurance and its allies have continued to work to limit and deny both insurance and care to far too many.