Health for Three-Thirds of the Nation - American Journal of Public Health

 PUBLIC HEALTH THEN AND NOW 

“Health for ThreeThirds of the Nation” Public Health Advocacy of Universal Access to Medical Care in the United States | Alan Derickson, PhD, MPH

ON NOVEMBER 15, 2000, THE Governing Council of the American Public Health Association (APHA) adopted a policy statement supporting a renewed campaign for universal health care in the United States. The statement recalled the association’s “longstanding commitment to the establishment of publicly funded and guaranteed comprehensive, affordable health care for all.”1 This essay demonstrates that the roots of universalism in the public health community run deeper than is commonly understood. Indeed, public health leaders played a unique role in fashioning some of the first arguments heard in this country in favor of providing medical care to all Americans. Historical scholarship on US health reform has concentrated on the many difficulties of enacting health insurance legislation. This understandable preoccupation with contentious politics has left the process of policy formulation in the shadows. Accordingly, the emergence of the ideal of universal access, which was generally not embodied in legislative proposals to insure segments of the working class, has received little attention. To be sure, a number of the major studies of

health reform take notice of the perennial problem of the inaccessibility of basic medical care to a sizable share of the American people. However, none of these studies focuses primarily on either the question of access or the principle of universality. Moreover, no historian has systematically pursued the universalist ideal to its wellsprings in public health in the 1920s.2 The scant literature on the engagement of public health professionals with these matters follows the general historiographic pattern. The decision of the APHA in 1944 to endorse national health insurance has attracted the most interest. Arthur Viseltear’s admirable account of the birth of the Medical Care Section of the APHA as a by-product of that controversy does not explore the rise of universalism. Similarly, Viseltear’s valuable essay “Compulsory Health Insurance and the Definition of Public Health” does not focus on the problem of access. Milton Roemer’s helpful analysis of the association’s participation in early initiatives to reshape the health care system also overlooks this facet of the story. Paul Starr’s insightful discussion of the shifting bounds of the public health domain does not em-

180 | Public Health Then and Now | Peer Reviewed | Derickson

The public health community has made important, original contributions to the debate over universal access to health services in the United States. Well before the decision of the American Public Health Association in 1944 to endorse a health plan encompassing virtually the entire populace, prominent public health practitioners and scholars embraced universality as an essential principle of health policy. Influenced by Arthur Newsholme, C.-E. A. Winslow began to promote this principle in the 1920s. Many others came to justify universal medical care as a corollary of the traditional ideal of all-inclusive public health services. By the 1940s, most leaders in the field saw national health insurance as the best way to attain universal access. For the past 30 years, advocates of universalism have asserted a social right to health services.

phasize the growing involvement of public health leaders in health care policy.3 It would be wrong to suggest that public health workers were the sole originators of the standard of all-inclusive access to health services. Although it is impossible within the confines of this essay to discuss all the early proponents of universalism, it is worthwhile to note in passing some of the other progenitors of this perspective. The small cohort of American universalists included representatives of the labor movement, the civil rights movement, medical academia, and political groups on the left.4 Proposals for universal access stood out as exceptional throughout the period prior to World War II. The initial wave of agitation for state health insurance emphasized forms of “workingmen’s insurance,” which sought to reach a fraction of the wageearning population only. Beginning in 1915, the American Association for Labor Legislation (AALL), the leading advocacy group of the Progressive Era, drafted a series of bills under which most employees making less than $100 per month qualified for state medical benefits. These propositions categorically

excluded domestic workers, agricultural workers, the unemployed, and the self-employed. In practice, they also would have left out the better-paid segment of the working class. The widely publicized AALL plans, products of the Wisconsin school of labor economics, framed the policy conversation in terms that made the task of universalists quite difficult.5

NEWSHOLME’S TOUR As Daniel Rodgers’s study of the transatlantic reform network has shown, until the middle of the 20th century North American progressives relied heavily on European ideas and experience. The impact of less-thanuniversal German and British legislation on US plans for health insurance in the 1910s is well known.6 However, another very different sort of foreign influence also shaped American thinking at that time. By his forceful advocacy of expanded public medical services, Sir Arthur Newsholme introduced the goal of universal access to health care into medical and public health circles in this country. In 1919, Arthur Newsholme came to the United States at the

American Journal of Public Health | February 2002, Vol 92, No. 2


invitation of William Henry Welch, director of the recently founded School of Hygiene and Public Health at Johns Hopkins University. Welch intended to have his old friend help establish a program in health administration. Newsholme came well prepared for the assignment. He had just retired as principal medical officer of Britain’s Local Government Board, where his decade of service culminated a long career in public health. Of perhaps most relevance at this juncture, Newsholme landed in America with a close familiarity with the implementation of a national health insurance system in his homeland since its enactment in 1911.7 The British visitor used his 2year stint at Johns Hopkins to articulate an expansive vision. Described by biographer John Eyler

as “a tireless lecturer,” Newsholme found frequent opportunities to proclaim universal public medicine a central component in future public health practice. With the historicism so characteristic of many at this time, he extrapolated from the trend toward greater governmental involvement in health affairs that he had observed over the course of his own career. As he put it (somewhat awkwardly) in a lecture at the New York Academy of Medicine in 1919, socialization of health services would eventually mean “the rendering available for every member of the community, irrespective of any necessary relation to the ordinary conditions of individual payment, of all the potentialities of preventive and curative medicine.”8 In Newsholme’s view, this expansive aim followed directly

February 2002, Vol 92, No. 2 | American Journal of Public Health

from the inclusive approach that already guided public health, both in Britain and in the United States. Environmental sanitation, water purification, food inspection, and other governmental interventions took for granted the goal of safeguarding all segments of the population. At the APHA annual meeting of 1919, Newsholme posed and answered a fundamental question: “What is public health work? It is best defined by stating its object, which is to secure the maximum attainable health of every member of the community.” From his perspective, governmental health officers would proceed to dismantle the barrier separating prevention from cure. He cited numerous precedents for such extensive state action: “If communal provision has been recog-

Oscar Ewing (right), administrator of the Federal Security Agency, represents the Truman administration’s campaign for national health insurance at the 1949 convention of the American Federation of Labor (AFL). Nelson Cruikshank (left) directed the AFL’s health reform efforts. (Photo courtesy of George Meany Memorial Archives.)

Derickson | Peer Reviewed | Public Health Then and Now | 181


Partisans of universal access in the Committee on the Costs of Medical Care, November 29, 1932. Left to right: Harry Moore, Michael Davis, C.-E. A. Winslow, Lewellys Barker. Davis, Winslow, and Barker were members of the committee; Moore served on its staff. (Charles-Edward Amory Winslow Papers, Manuscripts and Archives, Yale University Library.)

nized as a duty for police protection, for sanitation, for elementary education, should it not likewise be admitted for the more subtle and maleficent enemies of health?” Newsholme thus drew on his long professional experience in delineating a universalistic and comprehensive system of care.9 Newsholme’s belief in the value of extending public medicine rested on a critique of the limitations and contradictions of social insurance. He advised American audiences of the inability of British health insurance either to deliver preventive services or to lead indirectly to the prevention of disease. Moreover, he intently attacked that system’s exclusion of a sizable share of the population.10 This earnest message reinforced Americans’ scattered suggestions for an encompassing approach to health security. A number of US activists had noticed the contradiction between


their colleagues’ sweeping rhetoric of universal provision and their actual proposals for sickness benefits for a fraction of the wage-earning class. Accordingly, a few progressives were already moving to realign rhetoric and program. Throughout the 1910s, Michael Davis at the Boston Dispensary treated the question of access to health services as a concern of all, not just the working poor. In 1920, Hermann Biggs, New York State Commissioner of Health, promoted a plan allowing county health units to establish health centers that could serve all county residents.11

WINSLOW AT THE CROSSROADS Charles-Edward Amory Winslow was one of those impressed by Newsholme’s analysis. When the Briton came to New Haven in January 1920 to speak on “The Obstacles to and Ideals

of Health Progress,” he stayed with Winslow, then chair of the Department of Public Health at Yale. The American assured his guest that his visit would “mark an epoch in the public health campaign.” However, Winslow had already ventured some distance on the path toward espousing universal protection. In a paper entitled “The Untilled Fields of Public Health,” given at the American Association for the Advancement of Science just prior to Newsholme’s visit, Winslow enlarged on Biggs’s proposition: “I look to see our health departments in the coming years organizing diverse forms of sanitary and medical and nursing and social service in such fashion as to enable every citizen to realize his birthright of health and longevity. I look to see health centers, local district foci for the coordination of every form of health activity, scattered through our cities, as numerous as the school houses of today and as lavishly equipped.” Thus, at this juncture, he clearly based a claim to universal access to care on the strong rationale of a citizen’s rights. Yet much less clearly, he suggested only that the state would somehow organize or coordinate, but perhaps not itself deliver, the needed services.12 The appearance in 1922 of Gerald Morgan’s book Public Relief of Sickness lent further encouragement to Winslow’s advocacy of universal protection. Drawing on Biggs’s plan and the legislation that it had inspired, Morgan argued for community health centers to serve all. “Adequate medical treatment ought to be provided not to any particular class, like the working class, for a limited time and while in employment,” he maintained, “but at all times to the entire public,



since it is beyond the means and beyond the reach of even the socalled well-to-do.” Morgan’s recommendation that health reform concentrate on public delivery of medical care, not replacement of earnings lost while ill, was especially welcome to public health reformers like Winslow and Newsholme, who saw income maintenance as a discrete problem within the domain of social work, not public health. When asked in 1923 to serve on the General Administrative Council of the AALL, Winslow accepted the position but hastened to make known his disagreement with the association’s policy of seeking to combine insurance of lost income with insurance of health care. “I am pretty well convinced,” he told AALL secretary John Andrews, “that … the development of medical services should be worked out through the expansion of public health work.”13 Like Newsholme, Winslow sometimes adopted a historical approach in building a case for the integration of curative care into the agenda of public health. His 1923 monograph The Evolution and Significance of the Modern Public Health Campaign plotted a line of progress in state activity that culminated in current initiatives in health education and in detection and early treatment of disease. In projecting recent trends into the immediate future, Winslow acknowledged that he shared Newsholme’s doubts regarding the preventive capacity of compulsory sickness insurance. Characteristically mixing boldness and caution, he voiced support for “the gradual expansion of hospital and dispensary and nursing service under public or private auspices.” His

awareness of the conservatism of American society led him to promote incremental proposals.14 In “Public Health at the Crossroads,” his presidential address to the APHA meeting of 1926, this former protégé of William Sedgwick laid out the 3 major phases— environmental sanitation, bacteriologic control of communicable disorders, and education in personal hygiene—through which the field had passed during the preceding half century. Winslow predicted that the next major phase of progress would center on advances in early diagnosis and treatment of disease. In this scenario, he imagined the eventual disappearance of what he considered the outworn distinction between prevention and cure. Leadership in this historic project would and should come from public health workers. His position posed an especially daunting challenge to his audience at a time when a large share of the association’s membership consisted of private-practice physicians who served as municipal or county health officials on a part-time basis. Undoubtedly with this constituency in mind, Winslow maintained that “the health officer is the hub and the rest of us the spokes of the wheel of progress.”15 The scope of Winslow’s proposal was unambiguously universal. “In the last analysis,” he held, “it will be the duty of the health officer of the future to see that the people under his charge, in city or country, in palace or tenement, have the opportunity of receiving such [health] service as that outlined above and on terms which make it economically and psychologically easy of attainment.” Not committed to a governmental takeover of all health


“

The health officer is the hub and the rest of us the spokes of the wheel of progress.

care, Winslow saw the function of the community health officer as complementary to those of other providers in achieving universal access. In the same vein, he insisted that he was not simply suggesting compulsory health insurance or “any other panacea.” Instead, he called for experimentation that might make use of such devices as state health insurance.16 Winslow realized that even such a vague and qualified proposal for the expansion of public health activity would meet strong opposition. Mindful of the turf battle that any new foray into the diagnosis and treatment of disease would cause, he prepared his colleagues for the conflict to come. Given the reliance of opponents of reform on the pejorative term “socialized medicine,” Winslow warned his audience about the emptiness of such catch phrases. To that end, he quoted an observation by Royal Meeker, former US commissioner of labor statistics:

”

Many earnest people are afraid that social insurance will take away from the workingman his independence, initiative, and self-reliance which are so celebrated in song and story and transform him into a mere spoonfed mollycoddle. This would be a cruel calamity. But if the worst comes to the worst, I, for my part, would rather see a race of sturdy, contented, healthful mollycoddles, carefully fed, medically examined, physically fit, nursed in illness, and cared for in old age and at death as a matter of course in recognition of services rendered



militant, and increasingly powerful American Medical Association.17

THE COMMITTEE ON THE COSTS OF MEDICAL CARE

Isidore S. Falk, 1948. (Isidore S. Falk Papers, Manuscripts and Archives, Yale University Library.)

or for injuries suffered in performance of labor, than to see the most ferociously independent and self-reliant superrace of tubercular, rheumatic, and malarial cripples tottering unsocialistically along the socialized highways, reclining self-reliantly upon the communal benches of the public parks, and staring belligerently at the communal trees, flowers, and shrubbery, enjoying defiantly the social light of the great unsocialized sun, drinking individualistically the socialized water bubbling from the public fountain.

Winslow concluded by leaving his colleagues no room to evade their responsibilities: "No organization is so well fitted as the American Public Health Association to attack this problem from the broad aspect of community well-being." Despite this encouragement, the APHA was not ready to launch any such crusade. As John Duffy has explained so well, the 1920s was a time when the association remained fearful of the increasingly conservative, increasingly


Winslow did not confine himself to attempts to mobilize the APHA in the cause of universalism. He played a leading role in the creation of the Committee on the Cost of Medical Care (CCMC) in 1927. As chair of its executive committee, he did much to guide its deliberations over the following 5 years (during the midst of which, in 1930, the group renamed itself the Committee on the Costs of Medical Care). Winslow helped set a research agenda that explored not merely health care costs per se but also what rising costs entailed in terms of denial of services. An editorial in the American Journal of Public Health in July 1927 “welcome[d] any serious attempt to study the fundamental factors in the problem as to how the best medical care can be secured for the whole people at a minimum cost.” In spreading the gospel of universalism within a committee dominated by representatives of clinicians in private practice, Winslow enlisted 2 allies from public health. One of his former students, Isidore S. Falk, trained as a bacteriologist, used his appointment to the committee’s staff to develop expertise in the inchoate field of health services research. Falk would eventually become a leading champion of universal protection. However, as head of the research staff for the CCMC, Falk served in a technical capacity that gave him little opportunity to promote such expansive notions.18

In contrast, Falk’s immediate superior, Harry Moore, came to the committee from the US Public Health Service with an established reputation as an unabashed proponent of open access to basic health care. In American Medicine and the People’s Health, which appeared just as the committee was being formed, Moore observed that growing public awareness of the value of medical science had brought increased demand for wider availability of services based on that science. In an enumeration of principles, he made plain his priorities: “It is socially desirable that all the people receive the benefits of modern medicine. This is the most elementary and in some respects the most fundamental of these principles.” Moore classed opponents of universality with those social Darwinists who saw disease as a legitimate test for the survival of the fittest. He encouraged various small steps to achieve protection for all and suggested that compulsory health insurance was “not a dead issue.” Moore saw to it that every member of the CCMC received a copy of his book.19 The CCMC produced more than a score of major research reports, numerous miscellaneous publications, and a landmark final report. Immediately upon their release in the final report late in 1932, the committee’s recommendations regarding methods of financing health care attracted considerable attention. After much debate, the group of 48 had splintered, with the majority endorsing voluntary health insurance. One minority faction supported governmental insurance; another faction, based in the leadership of the American Medical Association, opposed any form of group insurance.



Five of the 6 members of the committee designated as representatives of public health— George Bigelow, Herman Bundesen, Haven Emerson, John Sundwall, and C.-E. A. Winslow— signed the majority report; the sixth public health member, Edgar Sydenstricker, refused to support any position. Somewhat obscured amid the furor and other strong reactions that greeted its conclusions regarding insurance was the CCMC’s commitment to health care for all.20 Yet the CCMC made universality a major tenet of American health policy. Indeed, this principle remained one of few objects of consensus within the sharply divided group. Committee chairman Ray Lyman Wilbur, the conservative president of Stanford University, whom Daniel Fox aptly called “a man for all factions,” took up the standard. Wilbur introduced the final report with this endorsement: “The report affords for the first time a scientific basis on which the people of every locality can attack the perplexing problem of providing adequate medical care for all persons at costs within their means. It is hoped that the report may thus aid materially in bringing greater health, efficiency, and happiness to all the people.” The majority report echoed Wilbur’s concerns: “The problem of providing satisfactory medical service to all the people of the United States at costs which they can meet is a pressing one.” This report went on to illuminate the inaccessibility of care to many poorer and rural Americans. The CCMC majority urged that the nation proceed incrementally to remedy this deficiency: “It may not be practicable to supply all the people’s needs at once, but any plan to be satisfactory must

provide for the continuous development of its component services until eventually they cover all the needs of all the people.” Predictably, the section of the majority report devoted to increased preventive measures took a universalistic stance.21

NEW DEAL POLITICS, UNSETTLED POLICIES In the week following the release of the final report of the CCMC, Franklin Roosevelt was elected president. The advent of the New Deal did not, however, bring with it any immediate embrace of universalism in health affairs. With the nation lost in the depths of a frightening depression, the principle of security overrode all others in setting social policy. Understandably, interventions to enhance security tended to address the needs of the most destitute, not the populace as a whole. In 1934 and 1935, the Committee on Economic Security devised plans for federal old-age pensions, federal–state unemployment insurance, and other measures that left out large segments of the American population. Along the same lines, as a result of the efforts of I. S. Falk, Edgar Sydenstricker, and other consultants, the committee considered incorporating into their plans social insurance of health expenses for only some needy members of society. However, apprehension about the reaction of the American Medical Association led the Roosevelt administration to drop health insurance from the Social Security Act.22 Advances in health protection during the early phase of the New Deal tended to be particularistic ones, embodied in a host of categorical programs. Because some of these


programs, like support for state industrial health activities under the Social Security Act, directly addressed traditional public health problems, the public health community was somewhat diverted from its emerging concern over medical care. Following closely on the critical reception of the final report of the CCMC, these political setbacks and shortcomings left no doubt as to the obstacles facing proponents of the universalistic perspective.23 The National Health Conference, held in July 1938, tried to resuscitate plans to place health insurance within the Social Security system. Even though the main proposal under discussion promised limited coverage, a number of conferees took this as an opportunity to push for general health security. Surgeon General Thomas Parran detected changes in societal assumptions and values. “It would appear to me at the present time,” Parran observed, “that people in general are beginning to take it for granted that an equal opportunity for health is a basic American right.” To be sure, most of those at the meeting who made a case for reform did so by reference to profound need or potential efficiencies. However, a few individuals followed Parran’s lead in asserting a new entitlement. Florence Greenberg of the Steel Workers Organizing Committee called on the Roosevelt administration to “take health from the list of luxuries to be bought only by money and add it to the list containing the ‘inalienable rights’ of every citizen.”24 The National Health Conference stirred excitement in public health circles. In a report on the event at the APHA annual meeting 3 months later, Surgeon Gen-



eral Parran reiterated his optimistic view that “an awakening public sentiment” might “make it possible for us to do far more than has yet been done in putting medical science to work for all of the people.” Abel Wolman, professor of sanitary engineering at Johns Hopkins, used his presidential address at this meeting to

“

American democratic medicine must be public health medicine, which means that it is preventive as well as curative medicine; . . . medicine delivered without distinction as to race, creed, occupation, or income.

”

reflect on his own participation in the federal conference. Wolman addressed the responsibilities implicit in health rights. To this end, he quoted from Edgar Sydenstricker’s recent redefinition of the scope of public health: “Society has a basic responsibility for assuring, to all its members, healthful conditions of housing and living, a reasonable degree of economic security, proper facilities for curative and preventive medicine and adequate medical care.” Wolman encouraged fellow APHA members to promote New Deal social reforms, including ensuring the accessibility of medical care. However, he stopped short of prescribing the methods for attaining universal access. The following year’s meeting heard Wolman’s successor, Edward Godfrey, return to the theme of unmet need among the third of the population unable to afford decent medical care. In an address entitled “Health for Three-Thirds of the Nation,” Godfrey expressed hope that reformers would be “sufficiently broad in their concepts


and clear in their desire for health for everyone to aid in producing an inclusive national health program.” He defined and defended “American democratic medicine”: “[I]t must be public health medicine, which means that it is preventive as well as curative medicine; . . . medicine delivered without distinction as to race, creed, occupation, or income.”25 Throughout the 1930s, support for governmental intervention gained strength from renewed advocacy of outright socialization of medicine. Compared with socialized medicine, social insurance appeared relatively tame and therefore attractive to some. With the publication in 1933 of Red Medicine: Socialized Health in Soviet Russia, Arthur Newsholme and John Kingsbury of the Milbank Memorial Fund offered a balanced overview of the emerging socialist system of health and welfare services (In this instance, balance resulted from the pairing of the pro-Soviet Kingsbury with the anti-Soviet Newsholme.) In their depiction of an accessible system of preventive and curative services, the authors illuminated a national commitment that derived from a sense of state responsibility. American progressives had little difficulty translating from the Russian: state responsibilities meant citizens’ rights. In 1937, Henry Sigerist, the eminent historian of medicine at Johns Hopkins, challenged this lukewarm appraisal with an enthusiastic report on his 2 tours of the Soviet Union. Sigerist presented the ready availability of free care and a preoccupation with disease prevention as salient features of the Soviet model, in an account that extolled the decommodification of medicine.26

Sigerist may have been uncritical in his embrace of the Soviet health system, but he was anything but doctrinaire in dealing with the American political situation. By the late 1930s, he had become a prominent proponent of governmental health insurance. Cognizant of the value of connecting radical demands to national traditions, he invoked the Founding Fathers in his 1941 book Medicine and Human Welfare: “We do not hesitate to accept the concept of man’s right to health or, more correctly, of man’s right fully to benefit from all known means for the protection and cultivation of health. … If we believe that life, liberty, and the pursuit of happiness are inalienable rights of man and that government is instituted to secure these rights, then we must conclude that man has a right to health and is entitled to having this right secured.” Sigerist thus joined the growing cohort pressing for universal provision as a citizen’s right.27

INTO THE LEGISLATIVE FRAY After 1938, the public health community increasingly became directly involved in national health politics. The process of engagement was not straightforward. Initially, public health leaders focused not on the goal of health care for all but rather on defending and advancing traditional methods of disease prevention within the New Deal agenda. This preoccupation kept the APHA at a distance from the health insurance provisions in bills sponsored by Senator Robert Wagner beginning in 1939. When Abel Wolman testified before the Senate in favor of Wagner’s National Health Bill in May 1939,



he gave only qualified support to its plan for federal grants to the states to set up health insurance programs. However, considering Wagner’s wide-ranging measure as a whole, Wolman did convey the universalistic preference of his organization: “We believe that the benefits of a national health program should be provided for the entire population.” The strong opposition of the American Medical Association and the tepid support of the Roosevelt administration guaranteed failure for this bill.28 World War II shifted the policy agenda to the left. Ideological mobilization for the war brought forth declarations of democratic ideals that encompassed unprecedented social rights. In 1941, President Roosevelt told the nation that the 4 fundamental freedoms for which the nation would fight included freedom from want and freedom from fear. Such assertions soon came to mean a promise of health protection. In January 1942, the National Resources Planning Board made entitlement to adequate health care part of the administration’s New Bill of Rights. Later that year, William Beveridge produced an authoritative plan for adding a national health service and a host of other social programs to the British welfare state. The Beveridge report received a great deal of notice in this country.29 In response to renewed demand for more extensive social protection, in mid-1943 Robert Wagner, along with James Murray in the Senate and John Dingell in the House of Representatives, introduced a sweeping plan to amend the Social Security Act to provide health insurance, disability insurance, and other new federal benefits. I. S. Falk, serving

as the director of the Bureau of Research and Statistics in the Social Security Board, played an important part in designing the health insurance section of this measure. The Social Security Board defended the proposal in terms that public health professionals could readily grasp: “Except for accidental injuries, the leading causes of death are now the slowly crippling diseases of middle age and old age, often ushered in by long periods of increasing disability. The attack on these forms of ill health cannot be made by mass methods such as chlorinating a water supply. … To prevent and curb such causes of disability and death requires the highly individualized services of physicians, technicians, and laboratories.” The board contended that “the direction of progress in health security in the United States lies increasingly in ensuring that all groups in the population can get … whatever medical care they need, not only as members of communities but also as individuals.” Although not truly universal in its health coverage, the Wagner-Murray-Dingell bill approached this ideal to an extent that its predecessor, the National Health Bill, had not.30 The APHA debated at length whether or not to endorse the health insurance section of Wagner-Murray-Dingell. Because Arthur Viseltear and others have discussed this episode quite thor-


oughly, my concern is limited to the fate of universality in that debate. When the association’s Committee on Administrative Practice turned to its Subcommittee on Medical Care in early 1944 to delineate principles for a comprehensive national health plan, the indefatigable Falk took on much of the subcommittee work. By the end of March 1944, Falk and his group had composed a tentative set of standards. Unsurprisingly, high on the list was an unequivocal commitment to universality: “All essential health services, curative as well as preventive, should be available to the entire population.” Six months later, the draft

Public health and labor activists helped to revive interest in universalistic reform in the early 1990s. (Photo courtesy of Paul W. Spear Archives.)



Paul B. Cornely, ca. 1955. Cornely played a leadership role in advocating universal access to health services from the 1940s onward. In 1969, he became the first African American president of the American Public Health Association. (Photo courtesy of History of Medicine Division, National Library of Medicine.

report of the subcommittee appeared in the American Journal of Public Health. It identified the first objective of a national medical care program to be to “make available to the entire population, regardless of the financial means of the individual, the family, or the community, all essential preventive, diagnostic, and curative services.” Recognizing the difficulty of immediately reaching this objective, the subcommittee called for comprehensive health care for all within 10 years. It looked to social insurance as the primary method to attain this aim. On October 4, 1944, the association’s Governing Council adopted this report (with revisions that did not pertain to universal access). With that decision,


the APHA officially endorsed health security for all.31

TOWARD A UNIVERSAL RIGHT In the half century since the APHA’s landmark decision, the public health community has consistently supported universal health care. When Congress resumed deliberations on the Wagner-Murray-Dingell bill in 1946, the APHA embraced the proposed legislation. At the same time, Joseph Mountin of the Public Health Service testified in congressional hearings that this measure would insure approximately 75% or 80% of the American people. In the interests of equity and simplicity, Mountin encouraged legislators to go further: “The Public Health Service would like to see this program assure medical services to 100 percent of the population.” The APHA institutionalized its increasing participation in the politics of medicine by creating a Medical Care Section in 1948. The section has served ever since as a forum for addressing questions about access to care.32 After 1950, a number of influences combined to foster a stronger emphasis on rights claims to health security, though the older justifications by needs and efficiencies also survived in public health circles. Certainly, the civil rights movement of the 1950s and 1960s reinforced a tendency to cast demands in terms of rights of citizenship. Some health reformers undoubtedly took encouragement from the Universal Declaration of Human Rights promulgated by the United Nations in 1948, which called for health care for all. Labor leaders had been advancing constitutional and quasi-

constitutional arguments for a citizen’s right to medical services since the 1930s. In this vein, the appearance of Walter Reuther, president of the United Auto Workers, at the 1968 meeting of the APHA was especially significant. After reminding his audience that 30 million Americans lacked health insurance, Reuther argued that “comprehensive high quality health care must be made available to every citizen as a matter of right.” He also used this occasion to announce the formation of the Committee of 100 for National Health Insurance. (The group soon renamed itself the Committee for National Health Insurance.) This group led a major, unsuccessful reform campaign over the course of the following decade.33 Rights claims became virtually ubiquitous in the late 1960s and early 1970s. The APHA approached the cause of health rights in a policy statement adopted on November 12, 1969. The statement edged up to, without simply proclaiming, an entitlement to health care: “Egalitarian principles and concepts of the rights of man are the high ideals upon which the United States was founded and which have shaped our political and social institutions. Health is no less a human aspiration than liberty and the pursuit of happiness. It should receive as firm a guarantee.” On this basis, the association reiterated its prescription for action: “A national program for universal, comprehensive, personal health services is required as a basic guarantee of equal opportunity for good health.” One year later, the APHA made clear that this meant forging a federal health insurance system. In the association’s view, financing such a system through a combination



of payroll taxes and general revenues would “insure health care as a social right.”34 In the period since 1970, many in public health have pursued the elusive ideal of health security for all. Although the APHA as an organization played a circumscribed role in health politics, numerous individuals took part in the battles of the past 3 decades. These public health practitioners and scholars upheld not only the principle of universality but also that of the indispensability of prevention in any successful reform. With its commitment to universal access so well established, perhaps the next major stage of public health involvement with this issue will focus not on the formulation of this ideal but rather on contributing to an effective campaign to realize it.35

About the Author The author is with the Department of Labor Studies and Industrial Relations, The Pennsylvania State University, University Park. Requests for reprints should be sent to Alan Derickson, PhD, MPH, Department of Labor Studies and Industrial Relations, 129 Willard Bldg, The Pennsylvania State University, University Park, PA 16802 (email: [email protected]). This article was accepted October 9, 2001.

Acknowledgments Some of the research for this project was supported by a grant from the Research and Graduate Studies Office, College of the Liberal Arts, Pennsylvania State University. I am also happy to acknowledge the very constructive criticisms provided by Ted Brown, Elizabeth Fee, Beatrix Hoffman, Margaret Spear, and the anonymous reviewers of this manuscript.

Endnotes 1. “American Public Health Association Policy Statement 20007: Support for a New Campaign for Universal Health Care,” American Journal of Public Health 91 (2001): 490–491; quotation on p. 490.

2. For overviews of health reform, see Paul Starr, The Social Transformation of American Medicine (New York: Basic Books, 1982), 233–449; Daniel M. Fox, Health Policies, Health Politics: The British and American Experience, 1911–1965 (Princeton, NJ: Princeton University Press, 1986); David Rothman, Beginnings Count: The Technological Imperative in American Health Care (New York: Oxford University Press, 1997); Compulsory Health Insurance: The Continuing American Debate, ed. Ronald Numbers (Westport, Conn: Greenwood Press, 1982). Of the above studies, only Starr’s (pp. 280–289) pays much attention to universalism. 3. Arthur Viseltear, Emergence of the Medical Care Section of the American Public Health Association, 1926–1948: A Chapter in the History of Medical Care in the United States (Washington, DC: American Public Health Association, 1972); Viseltear, “Compulsory Health Insurance and the Definition of Public Health,” in Compulsory Health Insurance, 25–54; Milton Roemer, “The American Public Health Association as a Force for Change in Medical Care,” Medical Care 11 (1973): 338–351; Starr, Social Transformation, 180–197. 4. Alan Derickson, “ ‘Take Health From the List of Luxuries’: Labor and the Right to Health Care, 1915–1949,” Labor History 41 (2000): 171–187; Alan Derickson, “Health Security for All? Social Unionism and Universal Health Insurance, 1935–1958,” Journal of American History 80 (1994): 1333–1356; David C. Jacobs, “The UAW and the Committee for National Health Insurance: The Contours of Social Unionism,” Advances in Industrial and Labor Relations 4 (1987): 119–140; Dona Cooper Hamilton and Charles V. Hamilton, The Dual Agenda: The African-American Struggle for Civil and Economic Equality (New York: Columbia University Press, 1997), 72–83, 217, 244–254; Making Medical History: The Life and Times of Henry E. Sigerist, ed. Elizabeth Fee and Theodore M. Brown (Baltimore: Johns Hopkins University Press, 1997). 5. American Association for Labor Legislation (AALL), “Health Insurance Standards,” American Labor Legislation Review 6 (1916): 237; Committee on Social Insurance, AALL, “Health Insurance: Tentative Draft of an Act,” American Labor Legislation Review 6 (1916): 241; Joseph Chamberlain, “Compulsory Health Insurance and Its Organization,” September 14, 1916, American Association for Labor Legislation Papers, 1905–1945, microfilm ed., 71 reels (Glen Rock, N J: Microfilming Corporation of America, 1973), reel 62; David A. Moss, Socializing Security: Progres-


sive-Era Economists and the Origins of American Social Policy (Cambridge, Mass: Harvard University Press, 1996), 136–157. 6. Daniel Rodgers, Atlantic Crossings: Social Politics in a Progressive Age (Cambridge, Mass: Belknap Press of Harvard University Press, 1998); Joseph Chamberlain to John B. Andrews, June 11, 1914, AALL Papers, reel 11; Margaret Hobbs, “Tendencies in Health Insurance Legislation,” American Labor Legislation Review 6 (1916): 138, 140; Beatrix Hoffman, The Wages of Sickness: The Politics of Health Insurance in Progressive America (Chapel Hill: University of North Carolina Press, 2000), passim, esp. 39–41, 45–55. 7. William H. Welch, “Foreword,” in Arthur Newsholme, Medicine and the State: The Relation between the Private and Official Practice of Medicine, with Special Reference to Public Health (Baltimore: Williams & Wilkins, 1932), 8; Arthur Newsholme, The Last Thirty Years in Public Health: Recollections and Reflections on My Official and Post-Official Life (London: George Allen & Unwin, 1936), 253–254, 264–266; Elizabeth Fee, Disease and Discovery: A History of the Johns Hopkins School of Hygiene and Public Health, 1916–1939 (Baltimore: Johns Hopkins University Press, 1987), 66–67, 79; John Eyler, Sir Arthur Newsholme and State Medicine, 1885–1935 (New York: Cambridge University Press, 1997), 341–346. 8. Eyler, Newsholme and State Medicine, 343 (quotation); Newsholme, Last Thirty Years, 248–250; Arthur Newsholme, Public Health and Insurance: American Addresses (Baltimore: Johns Hopkins University Press, 1920), 73 (quotation), 71–102, esp. 83–86, 98. 9. Newsholme, Public Health and Insurance, 43 (quotation), 101 (quotation), 42–102, 115, 187–188. On universalistic ideals (and practical shortcomings in achieving these ideals) in US public health at that time, see John Trask, “The Citizen and the Public Health: The Individual’s Relation to the Health of the Community,” Public Health Reports, 28 (1913): 2343; John Duffy, The Sanitarians: A History of American Public Health (Urbana: University of Illinois Press, 1990), 193–255. 10. Newsholme, Public Health and Insurance, 33–36, 66–70, 103–119. 11. Ralph Pumphrey, “Michael Davis and the Transformation of the Boston Dispensary, 1910–1920,” Bulletin of the History of Medicine 49 (1975): 463–465; Hermann Biggs, “Presidential Address,” Transactions of the Association of American Physicians 35 (1920): 1–6; C.-E. A. Winslow, The Life of Her-

mann M. Biggs, M.D., D.Sc., LL.D.: Physician and Statesman of the Public Health (Philadelphia: Lea & Febiger, 1929), 346–355, 364, 402; James Warbasse, “The Socialization of Medicine,” Journal of the American Medical Association 63 (1914): 264. 12. [C.-E. A. Winslow] to Arthur Newsholme, January 24, 1920 (quotation), C.-E. A. Winslow Papers, box 21, folder 529, Manuscripts and Archives, Yale University Library, New Haven, Conn; C.-E. A. Winslow, “The Untilled Fields of Public Health,” Modern Medicine 2 (1920): 189 (quotation); Newsholme, Public Health and Insurance, 157. For many insights into Winslow’s thought and action, see Arthur Viseltear, “C.-E. A. Winslow: His Era and His Contribution to Medical Care,” in Healing and History: Essays for George Rosen, ed. Charles Rosenberg (New York: Science History Publications, 1979), 205–228; Viseltear, “Compulsory Health Insurance,” 25–54. 13. Gerald Morgan, Public Relief of Sickness (New York: Macmillan, 1922), 158–159 (quotation), 158–161; [C.-E. A. Winslow] to John B. Andrews, January 16, 1923 (quotation), Winslow Papers, box 1, folder 16; [Winslow] to Arthur Newsholme, November 21, 1922, ibid., box 21, folder 529; Newsholme to Winslow, June 25, 1923, ibid. 14. C.-E. A. Winslow, The Evolution and Significance of the Modern Public Health Campaign (New Haven: Yale University Press, 1923), 63 (quotation), 49–65. 15. C.-E. A. Winslow, “Public Health at the Crossroads,” American Journal of Public Health 16 (1926): 1076 (quotation), 1077–1085; Roemer, “Force for Change,” 339–341. 16. Winslow, “Public Health at the Crossroads,” 1084 (quotation), 1083 (quotation). 17. Ibid., 1082 (Meeker quotation), 1084 (quotation); John Duffy, “The American Medical Profession and Public Health: From Support to Ambivalence,” Bulletin of the History of Medicine 53 (1979): 20–21. 18. “The Cost of Medical Care [editorial],” American Journal of Public Health 17 (1927): 723 (quotation); Douglas R. Parks, Expert Inquiry and Health Care Reform in New Era America: Herbert Hoover, Ray Lyman Wilbur, and the Travails of the Disinterested Experts (PhD dissertation, University of Iowa, 1994), 243; Milton Roemer, “I. S. Falk, the Committee on the Costs of Medical Care, and the Drive for National Health Insurance,” American Journal of Public Health 75 (1985): 841–848; Viseltear, “Winslow,” 214–215.



19. Harry H. Moore, American Medicine and the People’s Health: An Outline with Statistical Data on the Organization of Medicine in the United States, with Special Reference to the Adjustment of Medical Service to Social and Economic Change (New York: D. Appleton, 1927), 325 (quotation), 352 (quotation), 309–314, v–vii, 339; Harry Moore to C.-E. A. Winslow, January 7, 1927, Winslow Papers, box 62, folder 744; [Winslow] to Moore, October 29, 1927, ibid., folder 746; Executive Committee, Committee on the Cost of Medical Care, “Minutes,” May 18, 1927, ibid., box 63, folder 774; Moore to Ray Lyman Wilbur, September 28, 1927, Ray Lyman Wilbur Papers, box 95, folder 2, Special Collections and Archives, Lane Medical Library, Stanford University, Palo Alto, Calif. 20. Committee on the Costs of Medical Care, Medical Care for the American People: The Final Report of the Committee on the Costs of Medical Care (Chicago: University of Chicago Press, 1932), passim, esp. v–xi, 201. For an early indication that the committee intended to promote universal access, see Five-Year Program of the Committee on the Cost of Medical Care (Washington, DC: Committee on the Cost of Medical Care, 1928), 6, 7, 25. For historical studies that give little or no attention to the universal-access facet of this work, see Daniel Hirshfield, The Lost Reform: The Campaign for Compulsory Health Insurance in the United States from 1932 to 1943 (Cambridge, Mass: Harvard University Press, 1970), 31–37; Viseltear, “Compulsory Health Insurance,” 30–31; Starr, Social Transformation, 261–267; Fox, Health Policies, 45–51; Barbara Bridgman Perkins, “Economic Organization of Medicine and the Committee on the Costs of Medical Care,” American Journal of Public Health 88 (1998): 1721–1726. For an exception, see Rosemary Stevens, In Sickness and in Wealth: American Hospitals in the Twentieth Century (New York: Basic Books, 1989), 135, 154. 21. Fox, Health Policies, 46 (quotation); Committee on the Costs of Medical Care (CCMC), Medical Care for the American People, x (Wilbur quotation), 41–42 (quotation), 2–43, 118–119. On another occasion, Wilbur indicated that, its name notwithstanding, the CCMC had been created primarily to deal with the access problem. See Ray Lyman Wilbur, address, May 23, 1932, Wilbur Papers, box 94, folder 4. 22. Executive Committee, Technical Board on Economic Security, Committee on Economic Security (CES), “Minutes,” September 27, 1934, RG 47: Records of the Committee on Economic Security, box 1, folder: Minutes of Meetings of Executive Committee, Technical

Board on Economic Security, Archives II, National Archives, College Park, Md; Technical Board on Economic Security, CES, “Preliminary Recommendations of the Technical Board to the Committee on Economic Security,” no date [ca. October 1, 1934], ibid., folder: Technical Board Reports; Hirshfield, Lost Reform, 42–70; Edwin Witte, The Development of the Social Security Act: A Memorandum on the History of the Committee on Economic Security and Drafting and Legislative History of the Social Security Act (Madison: University of Wisconsin Press, 1962), passim, esp. 30, 173–174, 178n, 182–183, 187–188, 209. 23. Hirshfield, Lost Reform, 80–86; Witte, Development of Social Security Act, 165–167, 172; Irving Bernstein, A Caring Society: The New Deal, the Worker, and the Great Depression (Boston: Houghton Mifflin, 1985), 58–59; Michael R. Grey, New Deal Medicine: The Rural Health Programs of the Farm Security Administration (Baltimore: Johns Hopkins University Press, 1999). 24. US Interdepartmental Committee to Coordinate Health and Welfare Activities, Proceedings of the National Health Conference, 1938 (Washington, DC: Government Printing Office, 1938), 5 (Parran quotation), 84 (Greenberg quotation), 5–7, 29–64, 79, 84–85, 94–95, 119, 141. On labor’s participation in the conference, see Derickson, “Health Security for All,” 1338–1339; Derickson, “Take Health,” 171–172. 25. Thomas Parran, “The Health of the Nation,” American Journal of Public Health 28 (1938): 1376 (quotations), 1380; Abel Wolman, “A Century in Arrears,” ibid., 1375 (Sydenstricker quotation), 1369–1375; Edward Godfrey, “Health for Three-Thirds of the Nation,” ibid., 1285 (quotation), 1288 (quotation), 1283–1291. 26. Arthur Newsholme and John A. Kingsbury, Red Medicine: Socialized Health in Soviet Russia (Garden City, NY: Doubleday, Doran, 1933), vii, 221, 225, 268–270, 294, 310; Eyler, Newsholme and State Medicine, 365–373; Henry Sigerist, Socialized Medicine in the Soviet Union (New York: W. W. Norton, 1937), 86, 97, 98, 307; John F. Hutchinson, “Dances with Commissars: Sigerist and Soviet Medicine,” in Making Medical History, 229–258; Elizabeth Fee, “The Pleasures and Perils of Prophetic Advocacy: Socialized Medicine and the Politics of American Medical Reform,” ibid., 197–228, esp. 209. Newsholme undertook the Soviet investigation to supplement his survey of European systems for the Milbank Memorial Fund. That survey had led him to a more favorable view of state health insurance than he had held a decade ear-


lier; it also reaffirmed his commitment to universal provision. See Newsholme, Medicine and the State, passim, esp. 22, 29, 32, 36, 72, 76, 108–148. 27. Henry Sigerist, Medicine and Human Welfare (New Haven: Yale University Press, 1941), 101 (quotation), 102, 104; Henry Sigerist, “Socialized Medicine,” Yale Review 27 (1938): 463–481; Fee, “Pleasures and Perils,” 203–204, 210–216. 28. Abel Wolman, “Statement,” in US Senate, Committee on Education and Labor, To Establish a National Health Program: Hearings . . . on S. 1620, 76th Cong., 1st sess., 1939 (Washington, DC: Government Printing Office, 1939), 132 (quotation), 130–139; Hirshfield, Lost Reform, 114–153. 29. Franklin D. Roosevelt, “The Annual Message to the Congress,” in Roosevelt, The Public Papers and Addresses of Franklin Delano Roosevelt, comp. Samuel Rosenman, 13 vols. (New York: Macmillan, 1941), 9: 672; US National Resources Planning Board, National Resources Development Report for 1942 (Washington, DC: Government Printing Office, 1942), 3, 8, 9; William Beveridge, Social Insurance and Allied Services (New York: Macmillan, 1942); “The British White Paper [editorial],” American Journal of Public Health 34 (1944): 991–992; Edwin Witte, “America’s Post-War Social Security Plans,” American Economic Review 33 (1943): 825, 832; Hirshfield, Lost Reform, 163. 30. US Social Security Board, Eighth Annual Report, Fiscal Year 1942–1943 (Washington, DC: Government Printing Office, 1943), 24 (quotations); Monte Poen, Harry S. Truman Versus the Medical Lobby: The Genesis of Medicare (Columbia: University of Missouri Press, 1979), 32–34; I. S. Falk to Wilbur Cohen, January 11, 1943, I. S. Falk Papers, box 59, folder 514, Manuscripts and Archives, Yale University Library, New Haven, Conn; Falk, “Social Security for Everyone,” February 10, 1943, ibid., box 79, folder 859; “Social Security Conference,” February 5, 1944, Wilbur Cohen Papers, box 53, folder 4, Archives Division, State Historical Society of Wisconsin, Madison; Congressional Record 89: pt. 4 (June 3, 1943): 5261; Arthur Altmeyer, “How Can We Assure Adequate Health Service for All the People?” Social Security Bulletin 8 (1945): 12–17. 31. I. S. Falk, “Some Notes on a National Health Service and a General Medical-Care Program,” March 31, 1944 (quotation), Winslow Papers, box 10, folder 249; Subcommittee on Medical Care, Committee on Administrative Practice, APHA, “Preliminary Report on a National Program for Medical Care,”

American Journal of Public Health 34 (1944): 984 (quotation), 984–988; APHA, “Medical Care in a National Health Program: An Official Statement of the American Public Health Association, Adopted October 4, 1944,” ibid., 1252–1265; Viseltear, Emergence of the Medical Care Section, 12–16; Roemer, “Force for Change,” 341–344, 348. 32. J. W. Mountin, “Statement,” in US Senate, Committee on Education and Labor, National Health Program: Hearings … on S. 1606, 79th Cong., 2d sess., 1946 (Washington: Government Printing Office, 1946), 142 (quotation), 134–168; Reginald Atwater to James Murray, April 17, 1946, ibid., 527–531; Viseltear, Emergence of the Medical Care Section, 16–21; Roemer, “Force for Change,” 343–350. 33. Walter Reuther, “The Health Care Crisis: Where Do We Go from Here?” American Journal of Public Health 59 (1969): 15 (quotation), 12–20; Hamilton and Hamilton, Dual Agenda, passim; Derickson, “Take Health,” 181–187; Committee for National Health Insurance, “Organization Meeting,” January 30, 1969, Committee for National Health Insurance Collection, box 17, folder 2, Archives of Labor and Urban Affairs, Reuther Library, Wayne State University, Detroit; Jacobs, “UAW and Committee for National Health Insurance,” 119–140. For the persistent rhetoric of need, see APHA, “The Organization of Medical Care and the Health of the Nation,” American Journal of Public Health 54 (1964): 147–152; Isidore S. Falk, “Beyond Medicare,” ibid. 59 (1969): 608–619. 34. APHA, “A Medical Care Program for the Nation,” American Journal of Public Health 60 (1970): 189 (quotations), 189–190; APHA, “A National Program for Personal Health Services,” ibid. 61 (1971): 191 (quotation), 191–192. 35. It is beyond the scope of this essay to examine the part played by public health workers in the contest over access since 1970. For a few of the valuable contributions, see Dan E. Beauchamp, “Public Health as Social Justice,” Inquiry 13 (1976): 3–14; George Silver, “Is National Health Insurance the Question?” American Journal of Public Health 60 (1970): 1887–1890; Ruth Roemer, “The Right to Health Care—Gains and Gaps,” ibid. 78 (1988): 241–247; E. Richard Brown, “Principles for a National Health Program: A Framework for Analysis and Development,” Milbank Quarterly 66 (1988): 573–617, esp. 577–582. For signs of incipient activism, see “Universal Health Care Access Key Issue for APHA in 2001,” Nation’s Health, March 2001, p. 2.



