Social Work Health Care Reform
Stephen H. Gorin
  • LAST REVIEWED: 06 May 2015
  • LAST MODIFIED: 23 May 2012
  • DOI: 10.1093/obo/9780195389678-0022


Efforts to expand access to health care in the United States date back to at least 1798, when Congress enacted legislation for “the relief of sick and disabled Seamen.” Modern reform efforts began during the first two decades of the 20th century, largely through the efforts of the American Association for Labor Legislation, an organization of academics and other professionals, political figures, and business and labor officials. In 1912 Theodore Roosevelt’s Progressive Party called for “adoption of a system of social insurance,” including the “protection of home life against the hazards of sickness.” Despite this, national health insurance (NHI) failed to achieve broad public support. During World War I opponents of NHI succeeded in linking it with Germany and later the Soviet Union. These developments put reform advocates on the defensive, and by 1920, efforts for NHI had waned. The issue reemerged during the 1930s, when FDR’s Committee on Economic Security debated adding NHI to the Social Security Act. Strong opposition from the American Medical Association and others convinced Roosevelt not to include it. After Roosevelt’s death, Harry S Truman advocated NHI, but this effort was also unsuccessful. During the 1950s many advocates of NHI began advocating government coverage for older adults, who were then the most vulnerable segment of the population. In 1965 this effort culminated in the enactment of Medicare and, to the surprise of many, Medicaid. During the 1970s the escalation of health-care inflation forced reformers to begin addressing the issue of health-care costs. Employers and government officials increasingly turned to managed care as an alternative to the traditional fee-for-service system. The spread of managed care, in turn, raised questions and concerns about the quality of care. With the failure of President Clinton’s Health Security Act, which tried to combine competition, managed care, and government regulation, reform efforts again largely waned. The battle between Hillary Clinton and Barack Obama for the Democratic presidential nomination in 2008 again brought reform to the fore. Without support from Republicans, Congress in 2010 enacted the Affordable Care Act (ACA). This entry focuses on the history, background, and current status of three aspects of health care reform—coverage, cost, and quality. It also addresses the contentious debate over the future of the ACA, Medicaid, and Medicare.

General Overviews

Discussion of the history of health-care reform can be found in a wide range of sources, including work by social workers, sociologists, economists, political scientists, physicians, and others. Corning 1969 provides a detailed examination of the background and development of Medicare. Starr 1982, a Pulitzer Prize–winning analysis of the development of the medical profession, includes valuable material on reform efforts through the 1970s, and Mizrahi and Gorin 2008 presents an overview of reform efforts since the early 1900s, with emphasis on the role of social workers in formulating, developing, and advocating for social policies. Quadagno 2006 provides a historical and theoretical discussion of why the United States lacks national health insurance: the author particularly focuses on how powerful interest groups have mobilized to undermine public support for reform. Birn, et al. 2003; Hoffman 2003; and Hoffman 2009 offer three unique perspectives on the history of reform efforts. Moniz and Gorin 2010 presents an overview of development and current status of health and mental health policy in the United States.

Data Sources

A variety of sources provides information and data about health-care reform and related issues. The Center on Budget and Policy Priorities provides timely analyses of a wide range of issues, including health-care reform. Families USA: The Voice for Health Care Consumers, a leading health advocacy group, offers a range of information, including original studies and analyses about reform proposals and efforts at both the state and national levels. Health Beat, a blog sponsored by the Century Foundation, offers informed discussion of and opinions about health-care reform. The Center for Economic and Policy Research (CEPR) supplies data and commentary about reform issues, including a Health Care Budget Deficit Calculator, which demonstrates the impact of health-care inflation on the US budget deficit. includes a wide range of data on and analysis of the ACA. HealthReformGPS provides extensive information on health-care reform, including the ACA. The Health Reform Source provides a wide range of research, discussion, and analysis of the ACA and also examines the legislation’s impact on the states. The Commonwealth Fund seeks to promote the development of a “high performance health system” as well as original research, and addresses the needs of our “most vulnerable” individuals.


Although no journals focus solely on health-care reform, several include articles addressing reform and related issues. The American Journal of Public Health has included numerous articles on reform during its century of existence. Health Affairs plays a leading role in analyzing and dissecting reform proposals from a range of perspectives. Health Care Financing Review (now Medicare and Medicaid Research Review) provides demographic, cost, and other data related to Medicare and Medicaid. Health and Social Work, a publication of the National Association of Social Workers, publishes articles on a range of issues, including some on health-care reform. The Journal of Health, Politics, and Law has played a leading role in analysis and discussion of health-care reform. The Milbank Quarterly has addressed issues of health policy and reform from a range of perspectives since 1923.

Early Reform Efforts

Early efforts for health-care reform often overlapped with public health efforts. Garrett 2000 provides an overview of the development of public health in the United States; the author also presents valuable information about efforts to enact compulsory health insurance. Seager 1910, written by a Columbia University professor and leader in efforts to enact labor legislation, provides a pioneering discussion of social insurance with mention of the importance of health insurance. Starr 1982 examines the roots of social insurance in Europe and efforts to enact compulsory health insurance in the United States between the late 1800s and the Depression. Trattner 1999 discusses the development of public health in the United States and the role of social workers in advocating for health-care coverage. Seifert 1983 examines the effort to enact the Sheppard-Towner Act and the role played by social workers in it. Skocpol 1995 challenges the prevailing view that the United States lagged behind other nations in developing a welfare state. Theda Skocpol notes that after the Civil War, Congress enacted a generous system of benefits, which she calls the nation’s “first Social Security system,” for injured (and eventually all) veterans and their families and survivors. Terris 1945 reviews the attitude of public health workers toward national health insurance and called for “breaking down the barriers between preventive and curative medicine.” Williams 1932 examines efforts to enact compulsory health insurance between 1914 and 1920.

The Roosevelt and Truman Eras

Several health-care bills were introduced during the 1930s and 1940s. Although these bills succeeded in calling attention to issues, they had minimal success. Blumenthal and Morone 2010 examines FDR’s decision not to include national health insurance in his Social Security legislation. In a work commissioned by the Social Security Administration, Corning 1969 reviews efforts for reform between 1927 and 1940. Starr 1982 also discusses these efforts. This section includes several documents of historical interest. Draper 1939 presents President Roosevelt’s perspective on health-care reform, while Bauer 1946 presents the opposing view of the American Medical Association. Hollingsworth and Klem 1947 provides a detailed examination of the nation’s health at the end of World War II and an overview of approaches to voluntary and compulsory insurance. This section also includes Truman 1945, a presidential statement calling for a “comprehensive health program,” including national health insurance.

  • Bauer, L. H. 1946. The medical-care problem in the United States. New England Journal of Medicine 235.26: 924–928.

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    Critique by a trustee of the American Medical Association of the Wagner-Murray-Dingell bill, which would have created compulsory national health insurance. The author described this bill as “political medicine,” which he believed was “worse” than “socialized medicine” (p. 926).

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    • Blumenthal, D., and J. A. Morone. 2010. The Enigmatic angler. In The heart of power: Health and politics in the Oval Office. By David Blumenthal and James A. Morone, 21–56. Berkeley: Univ. of California Press.

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      Insightful discussion of failure to include national health insurance in the Social Security Act.

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    • Corning, P. A. 1969. The second round: 1927 to 1940. In The evolution of Medicare . . . from idea to law. By P. A. Corning, 23–52. Woodlawn, MD: Social Security Administration.

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      Overview of efforts to expand health-care coverage between 1927 and 1940. The author pays particular attention to “the Nation’s Health” and the role of pressure groups, particularly the American Medical Association, in determining political outcomes. Available online.

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      • Draper, W. F. 1939. A national health program. New England Journal of Medicine 220.2: 43–47.

        DOI: 10.1056/NEJM193901122200201Save Citation »Export Citation »E-mail Citation »

        Description by Roosevelt’s Assistant Surgeon General of the Administration’s proposed National Health Program, which would have provided federal funds to assist low-income people in obtaining health-care coverage and expanded hospital facilities. Introduced by Senator Robert Wagner, this bill was defeated.

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        • Hollingsworth, H., and M. C. Klem. 1947. Medical care. In America’s needs and resources, a Twentieth Century Fund survey which includes estimates for 1950 and 1960. Edited by J. Frederic Dewhurst and Associates, 236–272. New York: Twentieth Century Fund.

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          Comprehensive analysis of the health status of the population at the end of the war and proposals for reform.

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          • Starr, Paul. 1982. The mirage of reform. In The social transformation of American medicine. By Paul Starr, 266–289. New York: Basic Books.

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            Analysis of reform bills during the 1930s and 1940s.

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          • Truman, Harry S. 1945. Special message to the Congress recommending a comprehensive health program.

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            Includes call for incorporating health-care services into “our existing compulsory social insurance system.”

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            Medicare and Medicaid

            The enactment of Medicare and Medicaid in 1965 marked a turning point in the history of the US health-care system. This section presents material on the enactment and development of these critical programs.


            In the second edition of his classic work, Marmor 2000 examines the background and development of Medicare and its status at the turn of the 20th century. R. M. Ball, a long-time commissioner of Social Security and a leader in the effort for health-care reform, describes the strategy behind the enactment of Medicare in Ball 1995. Blumenthal and Morone 2008 examines the previously neglected story of Lyndon Johnson’s involvement in the enactment of Medicare. Davis and Collins 2006–2007 assesses the status of Medicare after forty years. Eichner and Vladeck 2005 (B. C. Vladeck is a former commissioner of Medicare) considers Medicare’s role in narrowing health disparities. In a brief article, Myers 2000, written by a former chief actuary of Social Security, discusses the development of the structure of Medicare and Medicaid. Oberlander 2003 examines the “fracturing” of the bipartisan consensus over Medicare and emergence of a new era of conflict and disagreement over the structure and future of that program.


            Kaiser Commission on Medicaid and the Uninsured 2010a and Kaiser Commission on Medicaid and the Uninsured 2010b present valuable information on various aspects of Medicaid, including its history and development. Olson 2010 discusses the role of political conflict in shaping Medicaid. Sommers and Epstein 2010 discusses the potential impact of the Affordable Care Act (ACA) on Medicaid and vice versa. Starr 1986 examines the impact of Medicaid on the health status of low-income people during the program’s first twenty years.

            The 1970s

            In response to health-care inflation, efforts for reform accelerated during the 1970s. The articles in Kotelchuck 1976 examine the changing structure of the health-care system with a particular focus on the emergence of “medical empires,” a “financial-planning complex,” and “health care profiteers.” Marmor, et al. 1990 examines efforts to control growing costs during the 1970s. Law 1974 traces the rise of Blue Cross as a central player in the nation’s health-care delivery system. In an influential article, Marmor 1977 discusses the nation’s growing health-care “crisis” and examines proposals to address it. Starr 1982 discusses the shifting goals of health-care reformers. This section also includes Richard Nixon’s proposal (Nixon 1971) for a “national health insurance partnership.”

            Managed Care

            Although initially viewed as a radical development, managed care, in its various forms, has come to dominate the health-care system. Dranove 2000 traces the transition from fee-for-service medicine to managed care. Carnoy, et al. 1976 critically examines the development of Kaiser-Permanente, one of the original health maintenance organizations (HMO). The authors of Ellwood and Enthoven 1995, being leading advocates of “managed competition,” present the Jackson Hole proposal for health-care reform. Luft 1987 examines the background, development, and performance of HMOs. MacLeod and Prussin 1973 examines the origins of and rationale for health maintenance organizations. Rothfeld 1976 discusses what prompted Richard Nixon’s decision to endorse and promote health maintenance organizations.

            The Reagan and George H. W. Bush Years

            The election of Ronald Reagan ushered in a new era of market-oriented approaches to social welfare policy. Stockman 1981, authored by Reagan’s first director of the Office of Management and Budget, outlined a “neoconservative” approach to reorganizing the health-care system. Despite the Reagan administration’s opposition to regulation, it did introduce a Prospective Payment System into Medicare. White 2008 argues that this and subsequent changes in Medicare reimbursement help explain the “slowdown” in Medicare’s excess spending growth. In 1988 Congress enacted (and Reagan signed) a controversial Medicare Catastrophic Coverage Act. Public opposition eventually forced the repeal of this act, which required older adults to finance the cost of coverage. This section includes Reagan’s statement (Reagan 1988) on signing the act and a discussion in Rice, et al. 1990 of why older adults opposed it.

            The Health Security Act

            The election of Bill Clinton in 1992 generated renewed interest in universal coverage and national health insurance. The ground for this was laid in part by the Pepper Commission in 1990 (see United States Congress 1990), a bipartisan commission appointed by Congress to investigate the nation’s health-care system and to make recommendations for reform. In a succinct discussion, Roberts and Clyde 1993 examines the problems with the health-care system and analyzes various proposals for reform. In Johnson and Broder 1996, two of the nation’s leading reporters provide an informed, panoramic view of the rise and fall of the Health Security Act. Paul Starr and W. A. Zelman, leading architects of Bill Clinton’s Health Security Act, describe the act’s approach to reform in Starr and Zelman 1993. Although it was widely believed that Clinton was an advocate of managed competition, Enthoven and Singer 1994 argues that by relying on “government regulation, not market forces, to control costs,” the act was actually a disguised version of a single-payer system. Altman 1995 explores the underlying roots of the act’s failure; he points in part to the increased willingness of “monied interests” to employ “the tools of political campaigns” to impact public opinion and the relative failure of liberals and independents to engage in the political process. Starr 1995 considers reasons why the act failed; his central conclusion was that reformers tried to “do too much at once, took too long, and ended up achieving nothing.” Hacker 1997 examines the origins and development of Bill Clinton’s efforts toward health-care reform and the reasons for his failure.

            State Children’s Health Insurance Program (SCHIP)

            Despite the failure of the Health Security Act, in 1997 Congress enacted SCHIP, which built on Medicaid to expand health-care coverage to children. Currie and Gruber 1996 examines the impact of Medicaid expansion on infant mortality. Holahan and Yemane 2009 examines cost-control efforts under Medicaid and suggest two additional approaches to “cost containment.” Lembrew 2007 discusses the background and impact of SCHIP and the challenges facing the program. Oberlander and Lyons 2009 argues that the history of SCHIIP demonstrates the need to move beyond incremental approaches to reform.

            The George W. Bush Years

            Although concern about terrorism dominated the nation’s political agenda during George W. Bush’s presidency, health care did not completely disappear as an issue. Barlett and Steele 2006 addresses the increasingly profit-driven nature of our health-care system and problems it created. The Economic Report of the President (Council of Economic Advisers 2004) reviews Bush’s approach to health-care reform. In 2003, with Bush’s support, Congress enacted the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) (Public Law 108–173), which created a Medicare Part D. Henry J. Kaiser Family Foundation 2006 reviews various aspects of the legislation at the time it went into effect in 2006. Anderson, et al. 2004 analyzes one of the most controversial aspects of the MMA, the so-called doughnut hole. Avorn 2006 also assesses problems with Part D. Broaddus and Park 2007 analyzes the impact on SCHIP of Bush’s budget proposal. The MMA also created health savings accounts, a key component of Bush’s health-care reform plan. Center on Budget and Policy Priorities 2006 analyzes problems with these accounts. Gruber 2006 analyzes the impact of Bush’s health-care proposals.

            The Affordable Care Act

            In 2008 the election of Barack Obama and a Democratic Congress reignited debate over health-care reform and led to enactment of the Affordable Care Act (ACA). Cassidy 2011 outlines ways the ACA might address excessive insurance rate increases. In Congressional Budget Office 2011, the director of the Congressional Budget Office presents CBO’s analysis of the budgetary impact of the ACA. In a letter to the Speaker of the House, Douglas W. Elmendorf summarized the impact on the federal budget of repealing the ACA (see Elmendorf 2011). D. Cutler, a leading health economist who worked on the Affordable Care Act, examined its potential for control costs (see Cutler 2010). Gorin, et al. 2010 considers the implications of the act for health inequalities. A special issue of Journal of Health Politics, Policy and Law (Grogan 2011) addresses various aspects of the Affordable Care Act. Oberlander and Marmor 2010 provides a discussion of the roots of and challenges facing the ACA. McDonough 2011 provides an inside account of the development and enactment of the ACA.

            Health Inequalities

            It has long been recognized that health inequalities based on race and ethnicity and gender and class are a serious problem in the United States. This section provides historical and current material on this critical issue. Isaacs and Schroeder 2004 examines class as a key determinant of population health. Eichner and Vladeck 2005 considers the role of Medicare and reducing health inequalities. Holland and Perrott 2005 addresses the health status of African Americans in 1938. Howell, et al. 2010 examines the impact of Medicaid and SCHIP expansions on racial differences in child mortality. Kawachi, et al. 2005 examines the role of race and class in creating health inequalities. LaVeist, et al. 2009 discusses the economic costs of health inequalities. Link and Phelan 2005 identifies socioeconomic factors as the “fundamental cause” of health inequalities. This section also includes the US Department of Health and Human Services 2011 plan for addressing inequalities.

            Future of Medicare

            In recent years, the future of Medicare has become a focus of intense discussion and debate. H. J. Aaron criticized Rep. Paul Ryan’s (R-WI) budget proposal, which according to Aaron, would “end” traditional (fee-for-service) Medicare for “everyone turning 65 in 2022 or later” (see Aaron 2011). Brooks 2011 defends Ryan’s controversial proposal. Gold 2003 discusses the limits of managed care and competition in controlling Medicare costs. House Committee on the Budget 2011 incorporates Rep. Paul Ryan’s (R-WI) controversial proposal to transform Medicare and Medicaid. This section also includes the Annual Report of the Medicare Trustees 2011, which examines the status of the Medicare Trust Funds. Van de Water 2011 discusses the impact of the Ryan proposal on future Medicare beneficiaries. Richard S. Foster, Medicare’s chief actuary, estimated the “financial and coverage effects through 2019” of the ACA (see Foster 2010).

            Single-Payer Proposals

            During the past several decades, some theorists, providers, and activists have argued that the United States could resolve its health-care problems by introducing a single-payer system, similar to the Canadian model. LeBow and White 2007 provides a detailed description of the flaws in the US health-care system. Bernstein and Marmor 2008 argues that the United States should expand Medicare to cover everyone. Geyman 2010 argues that despite some positive aspects, the ACA fell “so far short of needed health care reform that it” was “not much better than nothing.” This section also includes Physicians for a National Health Program 2011, written by a leading single-payer group, opposing efforts to repeal the ACA but urging the nation to move beyond it to “a single-payer, Medicare-for-all program.”

            Conservative Reform

            Although health-care reform is often associated with liberals, during the past several decades, conservatives have advocated reform proposals of their own. Pauly 2007 reevaluates his highly influential theory of moral hazard. Antos 2008 considers implications from the failure of the Health Security Act for future reform efforts. Miller 2010 places the ACA in the context of the long battle over health-care reform. The Heritage Foundation 2011, a leading conservative think-tank, critiques and advocates repeal of the ACA.

            Beyond Health-Care Coverage

            During the past few decades, scholars from Europe, North America, and elsewhere have gone beyond health-care coverage to examine the social determinants of health. Evans, et al. 1994 is a path-breaking book of readings addressing the role of social factors in determining population health. Marmot 2004, the author of which was knighted for his pioneering work, analyzes the role of social status in determining health outcomes. Schoeni, et al. 2010 examines the impact of social policies on health status. Wilkinson and Pickett 2009 summarizes a wide range of evidence to demonstrate the impact of inequality on population health. Arno, et al. 2011 considers the possible role of income-support programs in reducing inequalities and mortality among older adults.

            • Arno, Peter S., James S. House, Deborah Viola, and Clyde Schechter. 2011. Social Security and mortality: The role of income support policies and population health in the United States. Journal of Public Health Policy 32:234–250.

              DOI: 10.1057/jphp.2011.2Save Citation »Export Citation »E-mail Citation »

              Discussion of the possible role of Social Security and other income-support programs in reducing mortality among older adults; considers implications for 21st-century debates over reforming Social Security.

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              • Evans, Robert G., M. L. Barer, and Theodore R. Marmor, eds. 1994. Why are some people healthy and others not? The determinants of health of populations. New York: Aldine de Gruyter.

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                Early discussion of the impact of social factors on the health of populations.

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              • Marmot, Michael G. 2004. The status syndrome: How social standing affects our health and longevity. New York: Times Books.

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                Discussion by a leading epidemiologist of the impact of “social standing” on population health and recommendations for reform.

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              • Schoeni, R. F., J. House, G. A. Kaplan, and H. Pollack, eds. 2010. Making Americans healthier: Social and economic policy as health policy. New York: Russell Sage Foundation.

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                Examination of the impact on health status of social and economic policies.

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              • Wilkinson, Richard G., and Kate Pickett. 2009. The spirit level: Why more equal societies almost always do better. London: Allen Lane.

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                Seminal analysis of the impact of inequality on society as a whole and discussion of “different routes to greater equality” (p. 236).

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              Quality of Care

              With the spread of managed care, many advocates and others raised concern about the quality of care in our system. Bernstein, et al. 2011 reviews debate over “geographic variation in health care” and considers implications for health-care reform. Berwick, et al. 2008 (Berwick is current director of the Centers for Medicare and Medicaid Services) argues that expanding coverage, reducing costs, and improving quality are interdependent. Classen, et al. 2011 finds that the number of “adverse events” in hospitals was much higher than previously estimated. Wennberg, et al. 2008 discusses the impact of “unwarranted variation in medical practice” on health-care spending, an approach pioneered by Wennberg in the Dartmouth Health Atlas. Skinner and Fisher 2010 responds to a New York Times article critical of Dartmouth research. Marder, et al. 2011b examines geographical differences in “healthcare utilization and spending” among individuals with private insurance; they found that these variations did exist, but they differed from patterns of variation found among individuals with Medicare. Much attention has focused on geographical variation in spending by Medicare. Marder, et al. 2011a addresses geographical variation in spending for individuals with “employer-sponsored” health insurance (private insurance). This section also includes the Patient’s Bill of Rights under the Affordable Care Act created by the ACA.

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