The signing of the Patient Protection and Affordable Care Act in March 2010 has not quelled the bitter debate over the issue of health care reform. National health insurance (NHI) plans have been considered by many presidential administrations since the beginning of the 20th century. Harry Truman (Fig 1) was the first US president to propose a system of NHI, however, when he addressed Congress on November 19, 1945.1 He had already included “the right to adequate medical care and the opportunity to achieve and enjoy good health” in his proposed Economic Bill of Rights. For Truman, the words did not go far enough. As a Jackson County, Missouri, judge, he had seen firsthand the disastrous effects that illness could have on a working family through his responsibility for the county poorhouse.2 He later learned that one-third of Selective Service registrants were rejected during World War II. In addition, many soldiers were discharged for health problems unrelated to combat, and still more were treated for conditions that predated their military induction. In his speech, Truman enumerated basic problems with health care delivery, including high costs and loss of earnings during illness. In response, he proposed compulsory NHI for all Americans and expanded social insurance systems to include replacement of lost earnings.
NHI was not a new concept. Otto von Bismark initiated a compulsory health insurance program in Germany in 1883; its success led to the expansion of the concept of social insurance across Europe and the United States.3 In 1943, Senators Murray (Montana) and Wagner (New York), along with Congressman Dingell (Michigan), introduced the first US NHI bill. Then-President Roosevelt did not formally endorse the Wagner-Murray-Dingell (WMD) bill, but he was supportive.4 The bill died in committee, overshadowed by the war and the absence of congressional pressure by the president. Although he seemed to be more amenable to an endorsement of the program during his 1944 campaign and 1945 State of the Union address, President Roosevelt died before making any formal announcement.
Immediately after Truman's address, the WMD bill authors redrafted their legislation and presented it to Congress. The bill had 2 parts: Title I focused on public health services and maternal and child health care, and Title II established compulsory NHI.5 Initially, the likelihood of passage of the legislation seemed favorable. World War II was over, the nation had refocused on domestic issues, and Truman was fully committed to NHI. The majority of the public favored NHI, according to polls. The bill had powerful supporters in Eleanor Roosevelt, New York mayor Fiorello La Guardia, and National Broadcast Company founder David Sarnoff.6
However, it quickly became apparent that passage of the legislation was far from guaranteed. Although both chambers of the postwar Congress maintained a Democratic majority, the political tone was decidedly conservative. Public sentiment for the New Deal soured in the wartime climate of high taxes and elevated governmental control. President Truman was not well respected and was largely considered an accident of history with little political capital. Southern Democrats feared that federal involvement in health care might lead to federal action against segregation.7 The concept of compulsory NHI also ran afoul of the American Medical Association (AMA), one of the most powerful lobbies in the country.
In 1915, the AMA had supported compulsory NHI legislation.8 Times changed, and 2 years later the organization reversed its position and became opposed to federal insurance initiatives. Members believed that compulsory health care would limit physician autonomy and income and cause doctors to “become clock watchers and slaves of a system.”9 The AMA presented a counterproposal during the 1946 congressional hearings that touted private-insurance options. This promotion of private insurance was a major shift from the previous opposition the AMA had maintained to any interference of a third party in health care delivery.10
The AMA's plan was not the only alternative considered. Senator Robert Taft introduced the Taft-Smith-Ball bill, which authorized matching grants to states for the subsidization of private health insurance for the poor.4 The AMA favored the bill, but the Truman administration opposed it, fearing passage would distract attention from insurance for the general public. The measure died in the Senate Labor and Public Welfare Committee, which was chaired by Taft himself.
Senate Committee on Education and Labor hearings on the WMD bill continued throughout 1946, but the rancorous debate accomplished little. The conservative House Ways and Means Committee refused to hear the measure. New Deal-Fair Deal fatigue became the major issue in the 1946 midterm election, and Republicans gained the majority in both houses for the first time since 1929. Further action stalled.
President Truman made health insurance a primary issue in his 1948 campaign. He rebuked the AMA's claim that his health system was un-American by saying, “I put it to you. Is it un-American to visit the sick, aid the afflicted or comfort the dying? I thought that was simple Christianity.”11 His astounding November victory was accompanied by a return of Democratic majorities. Supporters of health reform claimed the election result was a mandate for NHI. The AMA was quick to go on the offensive, however. They hired a public-relations firm, Whitaker and Baxter, to organize its opposition. Also, for the first time in its history, a $25 fee was levied to fight health care reform.12 The AMA spent more than $4 million on the campaign—the largest lobbying effort in American history to that point.6 Its strategy was to equate Truman's program with socialized medicine and fuel growing fears of communism. Physician office pamphlets entitled “A Threat to Health—A Threat to Freedom!”13 were central to the AMA's educational campaign. In addition, the AMA obtained endorsements from more than 1800 national organizations including the American Bar Association, the American Legion, and the American Farm Bureau Federation.4 In his usual style, Truman later wrote that the AMA “had a mild case of hydrophobia over my suggestion that a health tax be levied by the Federal Government so the ordinary fellow could pay his doctor and hospital bills when an emergency arose in his family.”14
Although the AMA campaign had taken its toll, it was not solely responsible for the failure of NHI. Public support waned. Middle class favor for private insurance, the Korean War,15 and collective bargaining by unions for health benefits16 all contributed.
Despite the failure of the WMD bill, there were a few victories. The 1946 Hill-Burton Act, essentially Title I of the WMD bill, was enacted.4 Many years later, Truman would live to see Lyndon Johnson sign the Medicare Act on July 30, 1965, at the Truman Library. Thus, universal health insurance was established for the elderly
There are intriguing parallels, as well as differences, between the universal health care debates of the 1940s and those of today. The AMA was extremely powerful in 1948 and played a critical role in defeating President Truman's reforms. Organized medicine today has generally recognized the need for some form of universal health care. Even so, the current debate has become polarized to a degree that surprised the Obama administration and its allies. Just as Truman's opponents branded his bill as a form of communism, political pundits today have portrayed “Obamacare” as synonymous with “death panels” and “socialized medicine.” Recalling the 1948 debate reminds us how ideology and health care reform have long been intertwined in the United States.
- Accepted December 7, 2010.
- Address correspondence to Robert D. Schremmer, MD, Division of Emergency Medical Services, Children's Mercy Hospitals and Clinics, 2401 Gillham Rd, Kansas City, MO 64108. E-mail:
Drs Schremmer and Knapp attest that they have both made substantive intellectual contributions to this article including conception and design, data acquisition and interpretation, drafting and revising the article, and final approval of the submitted version.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
- NHI =
- national health insurance •
- EPA =
- Wagner-Murray-Dingell •
- AMA =
- American Medical Asscoiation
- Truman HS
- Derickson A
- Corning PA
- Polenberg RD
- 5.↵Joint statement of Senators James E. Murray of Montana, Robert F. Wagner of New York, J. Howard McGrath and Representative Dingell of Michigan. May 8, 1947. Records of Temporary Committees, Commissions and Boards: Records of the President's Commission on the Health Needs of the Nation (Record Group 220), Panels Hearings and Meetings Folder, Box 55. Truman Papers, Truman Library
- Greenberg J
- Hoffman C
- Maioni A
- Truman HS
- Campion FD
- 13.↵American Medical Association. Compulsory health insurance (pamphlet hand dated June 8, 1949). Records of Temporary Committees, Commissions and Boards: Records of the President's Commission on the Health Needs of the Nation (Record Group 220), General Correspondence Folder, Box 24. Truman Papers, Truman Library
- Truman H
- Starr P
- Copyright © 2011 by the American Academy of Pediatrics