Ifwe want a national health program -- and it is clear from polls over the years that most Americans do -- we're going about it the wrong way. It is not only Congress to which demands should be addressed, but state legislatures as well.
Those who call for a national health program have for nearly a century stubbornly concentrated on getting Congress to initiate it. In doing so, they have ignored 200 years of American history. You'd think they would have caught on by now to the futility of this approach.
Agitation for a national health program began in 1907, and bills have been introduced nearly every year since 1916. Not one of them has ever gotten out of committee. One administration after another has recommended national health insurance legislation, and Congress has received dozens of reports proposing such action over the years. The latest such episode is the report issued by the "Pepper" Committee, which was pronounced "dead on arrival" by members of the committee itself. It follows on the Report of the National Leadership Commission on Health Care this past year and will join it in the collection of forgotten proposals gathering dust on library shelves.
On the heels of this congressional report proposing a national health program, President Bush asked the secretary of health and human services, Louis Sullivan, to undertake another "study" and come up with a recommendation for a national health program. Dr. Sullivan will probably devote a year or so and several million dollars to producing another Congress-focused proposal to join in the archives the Wagner-Murray-Dingell bills, the Truman Report, the Eisenhower administration's "Goals for Americans," the Johnson administration's "Health Manpower Report," Walter Reuther's "Health Security bill," the Kennedy-Mills bill, and the Rockefeller Committee Report.
It has become increasingly clear that the present system is inequitable and irrational, denies access to millions of poor and minority citizens and suffers from uncontrollable costs and quality constraints. A program that will benefit all Americans -- which means a national program -- is unquestionably necessary. However, historically, national health and welfare legislation does not begin with congressional action, it ends there.
Welfare and health services were intended to be initiated in the states, as ordered in the 10th Amendment to the Constitution: "The powers not delegated to the United States by the Constitution, nor prohibited by it to the states, are reserved to the states"; and health and welfare were not mentioned as federal objectives in the Constitution.
When welfare and health legislation begin in the states, the effects of the laws are tested and the laws amended, refined and polished there. After their utility and value are demonstrated, the state benefits are extended, by congressional action, to the entire nation. For example, the elements of Social Security law existed in 24 states before the national Social Security Act was passed in 1935. The U.S. Congress didn't pass child labor legislation until 1912, yet by 1897 28 states already had child labor laws.
The innovative American idea of trying a social policy at a lesser level before making it national policy was considered a stroke of genius by 19th century observers. The British scholar, Lord Bryce, commented, "A comparatively small commonwealth like an American state easily makes and unmakes its laws; mistakes are not serious, for they are soon corrected; other states profit by the experience of a law or a method which has worked well or ill in the state that has tried it."
Justice Brandeis implied that state initiatives might actually be requirements for eventual national action. "It is one of the happy incidents of the federal system that a single courageous state may, if its citizens so choose, serve as a laboratory and try novel social and economic experiments without risk to the rest of the country."
Alice Rivlin, political and economic scholar, recommends strongly that social "innovation should be tried in enough places to establish its capacity to make a difference and the conditions under which it works best."
Where Congress has taken the initiative without previous state laws as guides -- as in the Medicare law, which had no state model -- the law is constantly being amended and is mired in controversy.
The failure of states to undertake a first step in these times of enormous medical-care costs may be the result of lack of federal support. There are so many bits and pieces of health-services responsibility, all with separate funding and administration, that a new law would only be an added financial burden. If this factor were taken into consideration, an effort to fashion a national health program could be undertaken by Congress and some state legislatures, jointly.
Dr. Sullivan can, if he chooses, take account of legislative history and recommend the traditional approach by encouraging initiation of trial programs in one or more states. His report could propose substantial financial support for a state or states that wish to undertake pilot programs of state comprehensive health services, providing universal eligibility. The experience gained from the state programs in delivering a satisfactory level of medical care, in efficient and economical payment mechanisms and in quality would be used as the framework for the national health program everyone desperately wants. In this way we might indeed have a national health program in the 21st century.
The writer, emeritus professor of public health at Yale, is writing a history of health policy in the United States.