Healthcare continues to make national headlines as Republican senators have twice failed to pass a bill in the Senate with enough support to repeal and replace the Affordable Care Act (ACA). How did we get here and why do so many Republicans want to make the ACA go away badly? To answer this question, you have to first understand the history of healthcare reform in the United States to provide context on how the ACA has been the most significant reform in American health care policy of the 21st century.

A major goal of the ACA–among its other goals of cost containment and increasing quality of care–was to expand health care coverage to the millions of Americans that lived without it. In 2010, the year ACA would go into effect, the number of Americans had reached an all-time high with 18% or about 55 million people that lacked health insurance.

People without health care insurance have shorter life expectancies and worse quality of life because they delay their care or can’t receive proper medical treatment. When they do get sick, the only place they could turn to was the ER which is an expensive and inadequate place to receive proper care for many non-emergent or chronic illnesses.

Health care in America is one of the most expensive in the world. Consequently, medical debt is the top reason of personal bankruptcies for many Americans. So it goes without saying that lacking health insurance in this country is a significant threat and a burden to the overall well being of its people.

Being one of the only OECD countries without universal coverage and having the worse healthcare performance of high-income countries, the voices for universal health care coverage are growing stronger. Healthcare reformers have been advocating for universal coverage for over 100 years in the U.S., but they have been met with significant opposition mainly from powerful interest groups.

The first national politician to advocate for universal healthcare coverage was Teddy Roosevelt. In 1912, as the Progressive Party’s candidate, he called for a social insurance plan which would include a national health insurance. Roosevelt lost the election and with it so did his national health insurance plan.

Twenty years later, his cousin, Franklin D. Roosevelt, would attempt to pick up where Teddy left off. F.D.R tried to pass a national health insurance plan–even attempting to link it to the Social Security Act of 1935.

Franklin RooseveltF.D.R addressed Congress in 1939 saying “The health of the people is a public concern; ill health is a major cause of suffering, economic loss, and dependency; good health is essential to the security and progress of the Nation”.  However, he met stiff resistance particularly with physician groups like the American Medical Association (AMA), and many state medical societies who were shouting it would lead the country into socialism. In fact, for many years, the AMA was a leading opponent of universal health care until the ACA in 2010.


After World War II, Harry Truman was elected in 1948 with an election promise to pass a single-payer national health insurance system with subsidies to pay for the poor. Again met with strong special interest opposition like the AMA, he failed to convince Congress to pass this reform.

LBJ Medicaire

On July 30, 1965, President Lyndon Johnson signs the Medicare Bill at the Harry S. Truman Library and Museum.

In 1965, the most significant health care legislation of the 20th century in America was signed into effect by Lyndon B. Johnson. With a strong majority Democratic support of both the Senate and the House of Representatives, Medicaid and Medicare programs would come into existence. Although not universal health care, these programs greatly expanded health care coverage by providing government-funded coverage for those unlikely to have health insurance- older adults, the disabled, and poor children.

Blog_Kennedy_HealthcareIn 1971, Senator Ted Kennedy would hold hearings around the country before issuing a report called “The Health Care Crisis in America.” He proposed a plan for a universal, single-payer system that would be run by the government and financed through payroll taxes. Again, this plan met heavy resistance with special interests like insurance companies. But also the plan was opposed by President Richard Nixon.

Richard_M._Nixon,_ca._1935_-_1982_-_NARA_-_530679Although Nixon opposed Kennedy’s single payer universal health care plan, he did concede that universal coverage is needed. “Government has a great role to play,” he said, “but we must always make sure that our doctors will be working for their patients and not for the federal government.”

So in response, Nixon proposed his own version of a universal health care reform plan mandating that employers provide private health insurance for employers and that government sponsored programs would cover everyone else. Nixon’s plan though would be derailed due to the Watergate scandal and his resignation in 1974.


First lady Hillary Rodham Clinton, holding a copy of the Clinton health-care plan during a visit to the Johns Hopkins, Oct. 28, 1993.

After Richard Nixon, no other president would make an effort for universal health care until 1992 when Bill Clinton took office. His wife, Hillary, would lead the White House Task Force to promote the plan called the Health Security Act. The plan was for universal coverage and controlling health care costs. The universal coverage though did not tout for public coverage. Rather the proposal was for an employer and individual mandates and competition among private insurers. To control costs, they proposed regional spending limits and caps on premium increases on health insurances.

The Clinton’s strategy to create a compromised bill incorporating liberal values (universal coverage) and conservative values (promote private health insurance business) backfired. Many moderate Republicans thought of the proposal as too liberal, and some Democrats thought it was too conservative. Therefore the Clinton’s were not able to muster up enough support for it to pass. Also, the health insurance companies successfully lobbied and campaigned against it as they thought it imposed too many regulations on the health insurance industry.


Mitt Romney signing the Massachusetts health care bill in 2006

While the history of health care reform at the federal level is necessary to understand the ACA, health care reform that occurred in the state of Massachusetts was also strongly influential. In 2006, Governor Mitt Romney signed into law “An Act Providing Access to Affordable, Quality, Accountable Health Care.” Many similar components that would be in ACA were first in this Massachusetts law: all state resident mandated to obtain health insurance, subsidized coverage for low-income people, the creation of a private health insurance market where consumers can choose their plans with eligible subsidies, and employer mandates.

One year later, in the 2007 Democratic primary elections, polls showed that the majority of Democrats thought health care reform should be a high priority–second to the economy– for the next president. Therefore if a Democratic president were to win the election, then health care reform would have a high likelihood to occur.

But in 2008, the financial crisis and the worst economic disaster since the Great Depression occurred. Many predicted that health care reform would be put on the backburner. Surprisingly, Barack Obama when elected held steadfastly and made health care reform a high priority for his administration. Although he had fierce opposition from Republicans and the rise of the Tea Party, the Obama administration was able to receive support from key interest groups. This was crucial as many prior administrations had failed to pass a comprehensive health care reform without support from these key interest groups.

Now, powerful groups like the American Medical Association who historically rejected universal health care and regulating costs were now buying into the notion that health care reform is badly needed. Other key groups from the pharmaceutical industry and health insurance industry were also throwing their support behind President Obama.

Although Obama favored a public option with universal coverage, political pragmatism would win to achieve health care reform.


On March 23, 2010, President Obama signed the ACA into law. The bill passed a Democratic house and senate without one single Republican support.

Today, according to the latest CDC data, 90% of Americans now have health care insurance. This among its many other reform changes in health care makes the ACA the most significant reform in American health care policy of the 21st century. The ACA has had its successes, but it also certainly had its challenges. And with the rising costs of health care and the poor population health outcomes compared to other high-income countries, there will indeed be more health care reform soon on the horizon. The question now is that with a Republican controlled White House, Senate and House in gridlock, how will health care reform move forward…… or will it go backward?

I am a gynecologic oncologist, a husband, and a father. My blog is mostly about our healthcare system and well-being, but occasionally I get inspired to write about other "stuff" too.

2 Comment on “A Brief American History of What Lead to Obamacare

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