A System in Shackles: Grassroots Movements and their Impact On and Against United States Healthcare Expansion
Sarah Galvani-Townsend, '25
Issue: 1
James Madison promoted “general welfare” in the preamble of the constitution, which should have cemented healthcare’s place as an American right. Yet when President Obama proposed expansion of healthcare access, he was simultaneously dubbed a Nazi and a Communist. After World War II, public healthcare was implemented in many European countries, including Britain and France. By contrast, an increasingly capitalistic Cold War America gave rise to private health insurance companies. Their success was contingent on squashing the public healthcare movement. The lucrative industry funneled inordinate resources into advertising, lobbyists and political campaigns. US healthcare expansion was impeded by the private healthcare industry, whose grassroots movements exploited the United States’ Cold War mindset. In turn, public healthcare movements were only successful in rebuffing the private healthcare industry when they harnessed grassroots support.
The end of World War II was marked by the dawn of the Cold War. The “Red Scare” occupied American hearts and minds as they lived in fear of Soviet ideology. Concomitantly, the private healthcare industry came under fire from myriad public healthcare proposals.[1] Health insurance companies harnessed Cold War fear, adopting an anti-communist rhetoric and redefining “free healthcare” as “socialized medicine,” tantamount to communism.[2] The phrase has retained its political power for six decades.[3]
The American Medical Association (AMA) formed to represent the interests of physicians, ardently opposed government involvement in healthcare, as they were concerned that it would reduce personal income. The AMA distributed posters to doctors’ offices, sporting slogans such as "Socialized medicine ... will undermine the democratic form of government."[4] They took to ferreting out doctors with leftist political ties, disguising their efforts as Cold War vigilantism. Into the late 1940s, the Association of Interns and Medical Students (AIMS) advocated for civil rights and national health insurance. The AMA wrote in their influential journal that AIMS was “exhibiting communistic tendencies,”[5] ominously warning that students who joined AIMS might “risk considerable embarrassment.”[6],[7] These accusations triggered the House Un-American Activities Committee (HUAC) to question physicians about their connections to AIMS, and subsequently other pro-public healthcare associations.[8] The physicians summoned by the HUAC were terminated from their positions.[9] Not only did the AMA’s Cold War propaganda derail individual doctors’ careers, but the resulting stigma skewed the profession’s political complexion.
Doctors, swayed by the AMA, refused patients who lacked money for medical care, forcing many Americans to leave sick and untreated or lose their life savings. To address this national crisis, Roosevelt outlined “the right to adequate medical care, and the right to achieve and enjoy good health” in his Bill of Rights.[10] In 1945, a proposal was tabled before Congress to introduce a national medical insurance program financed through social security payroll taxes. The Health Insurance Association of America (HIAA), joining forces with the AMA, funneled one million dollars (the equivalent of thirteen million today) into publicly defaming the proposal: the most expensive advertising effort in American history.[11] They filled the airways with rousing speeches, again invoking anti-communist sentiment: “American medicine… may determine whether America remains free, or whether we are to become a Socialist State, under the yoke of a Government bureaucracy.”[12] Their efforts were staggeringly effective. Between 1940 and 1950, the share of US citizens with private health coverage jumped from 9.1% to over 50%.[13] Without pressure from a strong country-wide grassroots movement in support of public healthcare, Roosevelt bowed to the AMA.[14]
In 1945, Californian Governor Earl Warren sought to implement a state healthcare bill — and his efforts looked promising. The California Medical Association, an affiliate of the AMA, funded an aggressive ad campaign, sending prepared speeches that included the slogan “Political medicine is bad medicine” to more than 9,000 doctors. They supplemented this grassroots movement by lobbying more than 500 newspaper editors. The AMA commissioned a powerful advertising firm that threatened to pull business from the newspapers if they published material in support of public healthcare. Not only did these newspapers sway public opinion, but politicians reading them received a false representation of the public’s beliefs. To further cement that perception, they printed prewritten letters:
Dear Senator:
Please vote against all Compulsory Health Insurance Bills pending before the Legislature. We have enough regimentation in this country now. Certainly we don’t want to be forced to go to “A State doctor,” or to pay for such a doctor whether we use him or not. That system was born in Germany—and is part and parcel of what our boys are fighting overseas. Let’s not adopt it here.
By fomenting fear and hatred in California, Warren’s bill failed to pass by just one vote.[15] His defeat foreshadowed a series of private insurance victories to come.
When President Truman proposed a national healthcare insurance plan, once again, the AMA and HIAA launched one of the great public relations campaigns of modern American politics, with The Doctor as its centerpiece. They lobbied the Postmaster General to print and and distribute government stamps featuring the painting:
I'm a paragraph. Click here to add your own text and edit me. It's easy.
The Doctor was a painting that depicted a home visit to a laborer’s sick child, adapted here for use as a postage stamp by the AMA.
AMA activists portrayed the painting as emblematic of all that would be lost if the state were to impose what they called “socialized” medicine and “fascist” health care. Strategically cultivating the image of a grassroots campaign, they coached medical societies on how to proselytize within their communities. “The Doctor arrived,” one Ohio physician reported in his hand-written thank you note for the poster. “He is in my waiting room witnessing effectively against the socialization of the practice of medicine.”
The AMA hosted scripted radio “interviews” with doctors and provided thousands of newspapers with feature stories, templates for editorials, and cartoons. They sponsored talks from disgruntled British doctors they called “exiles” or “refugees” from socialized medicine, claiming that doctors in the UK could spend only 3 minutes with each patient.[16] At a public rally, one AMA spokesperson said: “The AMA in its campaign is carrying its case to the people of America in a grass roots crusade which we hope, with your help, and the help of tens of thousands of others, will reach every corner of this country.” And it did. Their red baiting turned the President’s sensible, popular, and urgently needed legislative reform into a bogeyman so scary that it left a permanent scar on the world of healthcare reform.[17] In the face of these vitriolic attacks, and in defense of his own anti-Communism agenda, Truman dropped his plan for universal coverage.[18] By the early 1950s, the AMA had triumphed — a victory that would persist for more than a decade.[19], [20]
During this time, the AMA had joined forces with young Ronald Reagan to conduct a nationwide campaign called Operation Coffee Cup during the late 1950s and early 1960s. Their campaign opposed the Democrats' plans to extend Social Security to include health insurance for the elderly and destitute, later known as Medicare and Medicaid. As part of the AMA’s plan, doctors' wives would organize coffee meetings that convinced acquaintances to write letters to Congress opposing the program. In 1961, Ronald Reagan recorded a disc entitled “Ronald Reagan Speaks Out Against Socialized Medicine,” warning its audience of the "dangers" that free healthcare could bring. The recording was widely played at Operation Coffee Cup meetings, foreshadowing the policies implemented during his presidency.[21] "One of the traditional methods of imposing state-ism or socialism on a people has been by way of medicine," he informed the listener. After railing against “socialized medicine” for fifteen minutes, Reagan ended the recording by saying:
"When the American people want something from congress... if they make their wants known, congress does what the people want. So write. It's as simple as finding just the name of your congressman or senator... If we don't, I can assure you that… one day, you and I are going to spend our sunset days telling our children and our childrens' children what it was like in America when men were free."[22]
Through his expressive language, Reagan inspired passionate public opposition to Medicaid. He then gave them a call to action, telling them to write to their representatives — a classic grassroots campaign.
In his later inaugural address, President Reagan outlined his “intention to curb the size and influence of the federal establishment." He turned the ripples Operation Coffee Cup had created into waves. Almost immediately, Reagan proposed cuts to Medicaid and Medicare; and as a bipartisan neoliberal consensus gripped both major parties, the vision for universal healthcare was abolished from the political agenda.[23]
Following the neglect of the Reagan and Bush presidencies, millions of Americans remained without any health insurance whatsoever. And during the period from 1978 to 1990, the number of uninsured grew by 14 million people each year – to a total of 40 million Americans.[24] Bill Clinton’s healthcare plan sought to rectify the situation, but the nearly 1400-page proposal was far too complicated and confusing to inspire a popular movement on its behalf; activists concluded that “few could, or should, rally to this banner.”[25] Even though Clinton’s plan was modest in comparison to many of his Democratic predecessors, his bill was still met with an unprecedented negative PR campaign worth tens of millions.
The HIAA led opposition, worried that its smaller members would be forced out of business. While they ran effective phone and letter-writing campaigns to Congress, the HIAA’s “Harry and Louise” ads were the star of the Clinton-era healthcare debate. The ads featured a fictitious couple, Harry and Louise, who fanned fears of limited doctor choice by remarking, “They choose. We lose.”[26] The catchphrase sewed fears that government plans would take away autonomy by offering poor, fixed healthcare services. It encompassed statements aired in other ads, featuring quotes from newspapers: "There will be rationing... waiting lines will develop for medical care" or "You will have to settle for one of the low-budget health plans selected by the government" flooded televisions all over America. The ads also exploited traditionally American values. One was set on Thanksgiving day: "I'm just thankful we're all healthy!" "Let's hope the government keeps it that way," the actors read, before endorsing a private health insurance plan, “backed by thousands of Americans, like your mother and me." Each ad ended with a next step for the viewer to take: "Call this toll-free number for the facts!"[27] Citing “thousands of Americans” and depicting classic American families on American holidays inextricably linked traditional American values to private health insurance. Although less extreme, this rhetoric was a product of the “communist” “socialist” “Soviet” or “Un-American” labels popularized by the Cold War, still heavy in voters’ minds. The HIAA’s propaganda roused an incredible grassroots opposition to Clinton’s healthcare plan, and the reform fell short.
No movement of comparable size or intensity to the health insurance industry’s campaigns has arisen in the United States to demand universal health care. Public opinion generally ran in favor of health care reform, but popular approval was not matched by a movement for change.[28] Instead of general healthcare reform campaigns, the United States in the 20th century witnessed the flowering of social movements demanding access to the American Dream. Women, workers, African Americans, seniors, and welfare recipients, organized to change a society that made them second-class citizens.[29]
In 1965, these social movements coalesced into a united front, pushing to establish Medicaid and Medicare, which provided public insurance for the poor and elderly.[30] The Black healthcare movement, experienced in grassroots organization, swelled in support of the reform. Professional societies like the AMA barred black doctors; medical schools excluded black students, and most hospitals and health clinics segregated black patients. The AMA employed the same red-baiting and fear-based strategies they had used to foil Roosevelt, Truman, and Clinton’s plans. This time, the Civil Rights movement developed a counter message: Healthcare was a basic human right.[31] Radical activists called out coverage gaps, exposing the racial and class divisions at the heart of American society.[32] Fred Hampton, chairman of the Black Panther party, gave speeches rousing his supporters: “Now, today, in the black community, you have doctors who are more concerned with private wealth rather than public health." In cities such as Chicago, the Black Panthers established health clinics to deal with the egregious lack of healthcare access in poor Black communities.[33] To promote their message, Civil Rights activists joined forces with retiree groups to publicly campaign for Medicare. They launched petition drives and letter-writing campaigns, taking the AMA’s strategies and using them against the organization. Retirees disseminated “millions” of pieces of literature in an attempt to thwart AMA propaganda, and 14,000 seniors marched down the boardwalk at the Democratic Convention in Atlantic City. Americans were highly sympathetic toward the elderly as a group, which fettered the AMA and other opponents’ abilities to engage in open warfare against health reform, and in July 1965 Medicare became part of the Social Security Act.[34] After decades of campaigning, the US mounted its first large-scale grassroots movement for healthcare — and implemented its first reform bill.
Despite instituting Medicare, the healthcare system was still largely dominated by private companies, and Jesse Jackson’s proposed National Health Program highlighted the absurd economic inequality in the United States, criticizing the private insurance industry’s greed, and setting out a strong moral argument for the universal provision of publicly funded healthcare as a human right. "We have the best technology. We have sufficient doctors, hospitals, machines, and equipment. We spend enough money. But we lack the basic commitment to build a health care system to serve all the people,”[35] he quoted in one campaign speech, verbalizing the fundamental flaw in past healthcare activism. Through anecdotes about Cam, a diabetic killed by his lack of health insurance, he roused the grassroots support that the healthcare movement had lacked. Jackson came close to winning the Democratic nomination, gathering 40% of the delegates at the 1988 convention on a radical platform.[36] As a black man in the 1980s, his widespread support was a historic goal made possible by the grassroots movement he facilitated.
At the onset of the AIDS crisis, President Reagan’s spokesperson labeled a concerned journalist “gay” on national television, ridiculing his distress and repealing many of the measures Medicare had instituted.[37] In response, advocates worked to expand Medicaid benefits to include important AIDS services and treatments by targeting researchers, drug companies, and American citizens alike.[38],[39] They released the statement, “We believe that in a country with as much resources as we have that quality health care is a right,” and launched a publicity campaign featuring a poster that read, “Lack of Insurance Kills People with AIDS: Lack of insurance means lack of access to health care, and lack of health care means death.” Posters like these were ubiquitous during the AIDS movement, from handheld signs to pieces of paper plastered to utility poles.[40]
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An AIDS movement poster advertising a rally and covered in pro-healthcare slogans. The largest one, “Health care is a human right — not a business,” was originally invented by the Black Panther Party but has been used as a staple to advocate for free healthcare ever since.[41]
People with AIDS and HIV fighting for their lives led to unprecedented changes in the healthcare system.[42] By the end of his presidency, Reagan had pronounced AIDS “one of the top priorities in the US” and provided almost half a billion dollars for research on AIDS, faster drug trials, and pharmaceutical price reductions.[43] At no time has the connection between grassroots movements and healthcare reform been more powerful, and more successful, than during the AIDS crisis. As a result, 1990 saw the passage of the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act, announcing "This is the largest federal program focused on HIV… Many people who receive services through the RWHAP are uninsured or underserved."[44] The act was a huge step for gay rights and AIDS-specific care, but private insurance companies continued to dominate the US healthcare scene.[45]
The AMA has since stepped down from its anti-healthcare reform role, but The Partnership, a marketing and public relations agency, has taken up its mantle. Like Whitaker and Baxter, The Partnership is the new Goliath of the healthcare advertisement industry. Many of its ads feature a local citizen talking to the audience about government-run insurance systems that will force Americans to “pay more to wait longer for worse care.” The ads are effectively a modern Harry and Louise. Each ad features people who embody traditional American values — a firefighter, a teacher, a healthcare worker — all railing against public healthcare.[46] “The politicians may call it Medicare for All, Medicare buy-in, or the public option,” reads an ad run by the Partnership during September’s 2020 Democratic presidential debate. “But they mean the same thing.” And of the four candidates who stood shoulder to shoulder with Sanders in 2017, only one — Warren — is still running on single-payer health care.[47] The Partnership's propaganda is working, riding on its predecessors’ long legacy of political repression. Until this legacy is understood, the US cannot transcend it.
While doctors’ politics toward national health insurance are starting to shift, the toxic residue of these movements remains. The silencing of progressives and amplification of the private healthcare industry has long narrowed the horizons of what was possible in health care, and likely cost millions of lives. But the industry’s victories were only possible through grassroots movements inspired by Cold War propaganda. Throughout America’s history, other demands have been more immediate and even life-and-death than long-term change in the health care system: the right to organize, desegregation, reproductive rights, and disease research and drug access for AIDS. Local and incremental reforms have been more feasible to rally around than comprehensive change. In turn, the relentless opposition of medical insurance interests pushed reformers to design health care proposals around placating their opponents more than winning popular support. With the words, “Mankind are more disposed to suffer, while evils are sufferable, than to right themselves by abolishing the forms to which they are accustomed. But when a long train of abuses and usurpations, pursuing invariably the same Object evinces a design to reduce them under absolute Despotism, it is their right, it is their duty, to throw off such Government, and to provide new Guards for their future security," the Founding Fathers declared American independence. Two hundred and fifty years later, the US has yet to reflect that sentiment in its healthcare system. America has been left behind, bogged down by health insurance propaganda and the Cold War it exploited.
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Footnotes
[1] Mihajlo Jakovljevic et al., "Cold War Legacy in Public and Private Health Spending in Europe," Frontiers in Public Health 6 (August 6, 2018), https://doi.org/10.3389/fpubh.2018.00215.
[2] Paul B. Horton and Gerald R. Leslie, The Sociology of Social Problems, 4th ed. (New York: Appleton-Century-Crofts, 1970), 620.
[3] Jack E. Fincham, "The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care.," American Journal of Pharmaceutical Education 73, no. 7 (2009): accessed July 11, 2023, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2779642/.
[4] Oliver Garceau, "Organized Medicine Enforces Its `Party Line,'" Public Opinion Quarterly 4, no. 3 (September 1940): https://doi.org/10.1086/265421.
[5] "Resolution on Association of Interns [sic] and Medical Students," in JAMA Network, previously published in JAMA 137, no. 10 (July 3, 1948).
[6] "Resolution on Association of Interns [sic] and Medical Students," in JAMA Network, previously published in JAMA 137, no. 10 (July 3, 1948).
[7] "Report of Reference Committee on Hygiene and Public Health," in JAMA Network, previously published in JAMA 137, no. 17 (December 1948).
[8] Eighth Report of the Senate Fact-Finding Committee on Un-American Activities: Hearings on S. 79, 86-7, 152-3, 157 (1955).
[9] Merlin Chowkwanyun, "The Fall and Rise of Mid-Century Student Health Activism: Political Repression, McCarthyism, and the Association of Internes and Medical Students (1947–1953)," Journal of the History of Medicine and Allied Sciences 74, no. 2 (April 1, 2019): https://doi.org/10.1093/jhmas/jrz026.
[10] Franklin Delano Roosevelt, "FDR's Economic Bill of Rights," address, 1944, video, 1:34, YouTube, posted by Sssirob, 2010, accessed July 10, 2023, https://www.youtube.com/watch?v=effDfpKYcVo.
[11] Freddie Stuart, "Podcast: US election special #4 – Why does the US not have universal healthcare?," October 26, 2020, in ourEconomy, podcast, audio, 1:10:25, accessed July 10, 2023, https://www.opendemocracy.net/en/podcasts/ourvoices-podcast/podcast-us-election-special-4-why-does-the-us-not-have-universal-healthcare/.
[12] John Harley Warner, "The Doctor in Early Cold War America," The Lancet 381, no. 9876 (April 2013): accessed July 13, 2023, https://doi.org/10.1016/s0140-6736(13)60915-0.
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