How We Got Here: Why Americans Can't Seem to Ever Agree on A Good Health Care Fix

Republicans on Thursday got one step closer in their epic quest to repeal and replace the Affordable Care Act, aka "Obamacare."

Controversially drafted behind closed doors by Senate Majority Leader Mitch McConnell (R-KY) and a small group of his Republican colleagues, the Senate bill is, despite earlier pledges, broadly similar to legislation narrowly passed by House Republicans in May.  This NPR chart has a good side-by-side comparison of the  House and Senate bills and how they measure up against Obamacare.

Like the House version, the Senate bill would gut many of Obamacare's key provisions, including the "individual mandate," which now requires everyone to purchase insurance or pay a penalty.

The new bill would also repeal most of the taxes used to pay for the ACA.  Additionally, it would eliminate federal funding for Planned Parenthood and slash funding for Medicaid, a sweeping program that subsidizes health care for nearly 70 million people. And while the legislation proposes creating a new system of tax credits to help people buy insurance, the health overhaul would likely result in millions of lower-income Americans losing their coverage.

A vote is expected next week, although five Republican senators have already announced their opposition the bill in its current form, a move that would all but doom the effort.

Democrats, who universally oppose the legislation, were quick to express their disdain: "This is a bill designed to strip away heath care benefits and protections from Americans who need it most, in order to give a tax break to the folks who need it least," said Senate Minority Leader Chuck Schumer (D-NY).

This is just the latest chapter in the Republicans' tireless endeavor to destroy the ACA. Since it became law almost seven years ago, President Obama's signature health care reform has managed to survive countless attacks, two Supreme Court challenges and dozens of legislative assassination attempts.

But after the 2016 election gave Republicans control of both the White House and Congress, the ACA finally seemed doomed.

As a candidate, President Trump repeatedly pledged to dismantle it promising an alternative plan that would offer "insurance for everybody” while dramatically cutting costs (although he stopped short of providing any firm details).

Things got a good deal messier after that. Repealing the ACA without a reasonable replacement would cause millions of Americans to lose their health coverage, a prospect that sparked the ire of constituents in Republican districts across the country.

In fact, despite the Democrats' sweeping defeat in 2016, support for the ACA is oddly now at the highest level it's been in years.

America, the outlier

It’s safe to assume that just about everyone wants affordable health care. Why then is it so hard for Americans to come up with a decent health care fix that most of us can all at least marginally agree on?

Most of the world's other wealthy countries seem to have navigated this issue a lot more smoothly and effectively. Just about every other high-income nation spends significantly less than the U.S. does, yet delivers a higher quality health care available to all their residents, mostly through single-payer government systems.

In a recent study published in The Lancet medical journal,  researchers at the University of Washington created a global health care quality index by looking at 32 causes of death in 195 countries between 1990 to 2015. The U.S., the wealthiest, most powerful nation on earth, is ranked a dismal 80th, on par with Montenegro and Estonia.

Among citizens of the industrialized world, Americans have long been uniquely wary of too much government involvement in most aspects of life, but particularly health care. It's a skepticism rooted in the nation's longstanding emphasis on individualism, self-sufficiency and free markets, and America's distinct national aversion to anything resembling socialism.

Truman's big push

To begin to understand why the U.S. is such an outlier on the health care front, we need to go back to November 1945. That’s when President Harry Truman proposed a new health insurance program that would cover all Americans. His plan would have made the government centrally involved in providing health care. The plan was actually a far more radical approach than the ACA, which largely just expands access to private insurance.

Most Americans were initially receptive to Truman’s proposal; nearly 60 percent supported it, according to a Gallup Poll conducted after the president introduced it.

The immediate enthusiasm, though, worried the American Medical Association, which represented the business interests of doctors and was then one of the country's richest and most influential lobbies. A nationwide plan to make health care more affordable for patients, the AMA reasoned, would also make it less profitable for many private-practice physicians.

"Socialized medicine"

And so the group quickly got to work on an ingenious ad campaign centered on two powerful words: "socialized medicine."

Over the next few years, as Congress worked to craft a universal health care bill, the AMA invested in what was then the largest ad campaign in U.S. history, explicitly aimed at convincing Americans to reject Truman's plan.

"Would socialized medicine lead to socialization of other phases of American life?" one pamphlet posited. "Lenin thought so. He declared, 'Socialized medicine is the keystone to the arch of the socialist state.' "

(The quote was completely made up, but took hold nonetheless.)

When the plan was introduced in Congress, Sen. Robert Taft, a conservative Republican from Ohio, interrupted his Democratic colleague, stating that the bill was "the most socialistic measure this Congress has ever had before it."

National health insurance, Taft suggested, came directly from the Soviet constitution. He announced that Republicans would boycott the hearings, and then promptly marched out of the Senate chamber.

The AMA continued to push the "socialized medicine" angle. In one editorial, the group warned that national health insurance would turn doctors into "slaves." In one Tallahassee, hospital, doctors slipped political ads onto patients' breakfast trays.

Ahead of the 1950 midterm elections, the AMA spent more than $1 million on radio and TV ads -- far more than the government could spend to defend it. As one Truman ally ruefully noted, countering the AMA's ads was like "trying to put out a forest fire with a sprinkling can."

When the election results rolled in, Democrats lost nearly 30 seats in the House and five in the Senate. Public support for the proposal had plummeted, dropping from 60 to 24 percent approval in just five years.

And so the prospect of national health insurance was dead, for the time being at least. Over the following decades, the AMA would go on to fight additional government health-related reform proposals. This included a campaign against Medicare – a battle it did not win, even with the star power of then-actor Ronald Reagan as its spokesman. Reagan took to the airwaves to scare people into opposing the program, warning that if it went forward, "you and I are going to spend our sunset years telling our children and our children's children what it once was like in America when men were free."

The 1961 recording of Reagan was part of Operation Coffee Cup, an elaborate AMA effort to prevent the government from diverting any existing public funding towards paying for health insurance for the elderly and the poor.

Related: Back in the Day Medicare Had Its Haters Too

The effort, of course, ultimately failed. In 1965, President Lyndon Johnson signed the bill that created the Medicare and Medicaid federal health insurance programs for Americans ages 65 and up (regardless of income) and low-income residents. To this day, Medicare — that harbinger of “socialism” and destroyer of freedom that Reagan warned about— remains one of the most popular federal programs, approved by an overwhelming majority of Democrats and Republicans.

A change of heart

In 2010, the AMA changed its tune and moved to support federal health reform -- thanks in part to some major behind-the-scenes horse-trading. Today, the AMA's website refers to Obamacare as "a tremendous step forward on the path toward meaningful health system reform." The group has since implored Republicans not to repeal the ACA without offering an adequate replacement plan, and has opposed previous Republican alternative proposals.

The AMA, though, couldn't put the "socialized medicine" genie back in the bottle, and today the term retains the powerful pariah status in American political discourse that the lobbying group helped establish more than half a century ago in its battle against national health care reform.