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At one point in time, the U.S. health care system was dominated by physicians who worked in private practice as independent practitioners and was even described as a cottage industry since many physicians had their offices in their homes (Starr 1982). During that time period (up to 1900 at least and probably later), most people who had other options tried to avoid hospitals, because hospitals were viewed as a place to go to die for people with no other option and for people who were too poor to be able to remain in their homes. In addition, during the same time frame, there was not much care that could be provided for a person in the hospital that could not occur in the homes of people of economic means. This worked as the system for some period of time. Most people paid doctors as they received their care, and health insurance was not important for most people to obtain care. By 1900, there began to be some types of health insurance policies that people could purchase, often as a mix of coverage for actual health care costs and coverage for being out of work. Gradually, sick leave policies and disability policies replaced those aspects of health insurance, and health insurance became coverage for the major health care costs. Discussions grew about the need for people to have coverage. This related to improvements in medicine and surgery, so that surgery became safer and less scary through the use of anesthesia and an understanding of the need to control infection to facilitate safe recovery from surgery. New technologies such as X-ray machines also made the use of hospital services desirable, and people then wanted a way to pay the higher medical bills. During the presidency of Theodore Roosevelt, the first major attempt to pass some type of heath reform and health care coverage for many Americans occurred. During the same period, the efforts of the labor movement in the United States and such groups as the American Association for Labor also began, with these groups pushing health insurance programs mostly through state government efforts prior to World War I.

In 1921, a partial effort to provide health insurance coverage to mothers and children was passed: the Maternity and Infancy Act (also known as the Sheppard-Towner Act). This was a grant to states in the area of health and was an early successful effort to expand the role of the federal government into the provision of health care assistance to specialized groups of citizens. Although the goals of this program may seem simple and not controversial today, the program was very controversial in the 1920s and generated great criticism from conservative political groups and from the American Medical Association. The criticism was loud, and the commitment to the program by the political powers of the time was fairly limited, so the act was not renewed in 1929 and the program ceased to exist.

The idea of a Medicare program, or provision of health care insurance for the elderly, was rejected as part of the Social Security legislation in the 1930s because of opposition from the American Medical Association. Franklin Roosevelt wanted to be sure that the essential Social Security legislation creating an old-age pension system was enacted and quickly backed off from a Medicare-type provision when it became clear that it would be more controversial than the rest of the program and could potentially threaten the passage of the overall Social Security legislation. Although Medicare-type legislation continued to be introduced into most sessions of Congress once World War II ended, these pieces of legislation had little chance of success in the late 1940s and 1950s. Medicare did eventually pass, of course, in 1965 as part of the Great Society legislative efforts of President Lyndon Johnson. This program was created as a federally administered program, with the same benefits for all Social Security recipients regardless of which state they resided in. The program was designed to be similar to the health insurance that most working Americans had through their jobs at that time (although the latter was privately contracted between employers and insurers). At the same time, the Medicaid program that provided health coverage to selected groups of the poor was also passed, though as a federal-state joint program rather than as a national program. Over the past 40-plus years, both of these programs have become the major efforts of the government in the provision of health care insurance and health care services to parts of the U.S. population. They have also grown to be very complex programs, with many detailed and specific provisions and many important limitations that have been the subject of much critique and many policy debates. Both programs have changed and evolved a great deal...

Bibliography:

Greenwald, Howard P., Health Care in the United States: Organization, Management, Policy. San Francisco: Jossey-Bass, 2010.

Kronenfeld, Jennie Jacobs, and Michael Kronenfeld, Health Care Reform in America. Santa Barbara, CA: ABC-CLIO, 2004.

Marmor, Theodore H., The Politics of Medicare, 2d ed. New York: Aldine De Gruyer, 2000.

Skocpol, Theda, Protecting Soldiers and Mothers: The Political Origins of Social Policy in the United States. Cambridge, MA: Harvard University Press, 1992.

Starr, Paul, The Social Transformation of American Medicine: The Rise of a Sovereign Profession and the Making of a Vast Industry. New York: Basic Books, 1982.

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