Private insurers still managed the bulk of health care financing after the passage of Medicare and Medicaid in 1965. Massive opposition from conservative medical lobbies and a perilous legislative path forward meant that Medicaid received less attention than Medicare in the drafting process. In a period of low unemployment like the 1960s, few policy-makers assumed that Medicaid would rival Medicare in size. As of 2019, Medicaid spent three-fourths the total of Medicare, making the programs functionally equivalent in size. Today, public insurance comprises a solid one-third of the total share of health care financing.
Yet, since at least Theodore Roosevelt, the pursuit of national health insurance has always been within the realm of—if not at the center of—American politics. Still, the movement for universal health care has hardly marched in lockstep with the contingencies of public health. In this sense, not much has narrowed the chasm between public health and health care in the United States. Understanding the history of what formally separates public health from health care explains how poorly this groundbreaking legislation served disease prevention.
DSJ: Of course, the shift at this time from health care policies focused on infectious disease and the diseases of the poor to health care policies preparing for chronic illness and long-term care coincided with the civil rights movement. Why is this significant?
GA: Much of the movement for universal health care emerged from eminently practical efforts to aid activists injured by bigots. After the fall of de jure segregation, though, groups like the Medical Committee for Human Rights moved from triage to advocating for universal health care, but these efforts faltered before organized conservative opposition in the 1970s and 1980s. As a result, narratives about disease-specific groups—ranging from the women’s liberation movement’s breast-cancer and reproductive-health activism to the movement to stop AIDS—dominate our conception of the late 20th century.
While these movements articulated a moral critique of the medically damaging effects of leaving people uninsured, efforts to expand care also ran into poor economic timing. By 1973, inflation unshackled the preexisting racial resentment against the welfare state, providing cover for welfare state retrenchment beginning with Nixon. There’s a strong whiff of fiscal hawks buffeting the same rhetoric today against the $3.5 trillion budget reconciliation bill being debated in Congress. Much like the 1970s, concern about inflation has become a bipartisan affair, making passage of the bill a thorn in the side of the ruling party.