In Washington, President Bush has just vetoed a Democratic bill to extend the State Children's Health Insurance Program for low-income children. On the campaign trail, Democratic candidates are unveiling plans to fix the health-care system, only to be denounced by their Republican rivals. In both cases, enemies of change are wheeling out an old slayer of reform proposals past. "When you hear Democrats in particular talk about single-mandated health care, universal health care," Rudy Giuliani, the GOP front-runner for 2008, said recently, "what they're talking about is socialized medicine." Can the socialized medicine warhorse again be pressed into duty? Or has the passing of the Communist menace rendered it obsolete?
To some, the prospect that socialized medicine would still frighten anyone is absurd. Fears that "creeping socialism" might insidiously erode American freedoms are a relic of a distant age, like worries about fluoride in the water. Even so, the socialized medicine meme may have transcended the fevered ideological climate that spawned it. The words retain a talismanic power—a power that will soon be tested again.
As Paul Starr explains in his classic Social Transformation of American Medicine, the idea of government-run health care dates to the Progressive Era. Originally called "compulsory health insurance," it enjoyed favor in the 1910s among many quarters, including the American Medical Association. Many doctors expected that national insurance would encourage preventive medicine, thus saving money and lives. But as the debate heated up, doctors began to worry that it would hurt their incomes, and they banded with business groups like the National Association of Manufacturers to oppose reform. American entry into World War I tabled consideration of the issue, and the postwar Red Scare, Starr notes, "buried it in an avalanche of anticommunist rhetoric."
Already in these years, critics of national health care were playing to fears of an oppressive state. But socialized medicine wasn't yet the epithet of choice. In fact, that term initially carried no pejorative taint. Its first appearance in the Times, in 1917, came in a positive context: Otto P. Geier, chairman of the Preventive Medicine Section of the AMA, was quoted praising socialized medicine as a way to "discover disease in its incipiency," help end "venereal diseases, alcoholism, tuberculosis," and "make a fundamental contribution to social welfare."
When the campaign for national health insurance revived, however, in the 1930s—spurred by the Depression and the election of Franklin Roosevelt—socialized medicine emerged as a robust rhetorical weapon to blunt reform. As linguist Geoffrey Nunberg has discovered in a decade-by-decade analysis of the phrase's use in the New York Times, socialized appeared in the paper 105 times in the 1910s, socialized medicine just once. In contrast, in the 1930s, socialized appeared 706 times, and socialized medicine 234 times. The phrase, now routinely used negatively, had attained buzzword status.
Ironically, if a moment existed when reform was most likely to withstand cries of Bolshevism, it was the radical 1930s. Indeed, in the New Deal era, even some doctors looked anew at national health insurance. After all, since hard times were deterring people from seeing their physicians, physicians were losing business. Some doctors concluded that if the government provided insurance, their pocketbook woes would ease along with their patients'. Alas, FDR chose first to pass unemployment insurance and Social Security. By the time health-care reform topped his agenda, in 1939, he had lost the strong congressional support he had enjoyed in his first six years.
Succeeding Roosevelt in 1945, Harry Truman made national health insurance a priority. Picking up on FDR's Economic Bill of Rights, Truman proposed a single system that would cover everyone, with the government picking up the tab for the premiums of the poor. But the Cold War was aborning, and suspicions of anything that smacked of socialism were deepening. (Fittingly, uses of socialized medicine in the Times peaked in the 1950s—the time of the second Red Scare—with 454 uses, according to Nunberg's data.) Pre-emptively, he insisted, "This is not socialized medicine," as he revealed his plan to the public.
Polls showed early public support for Truman's plan. But he ended up losing the political battle. "I consider it socialism," huffed powerful Republican Sen. Robert Taft of Ohio about the plan, ignoring Truman's attempt to take that charge off the table. "It is to my mind the most socialistic measure this Congress has ever had before it." The Democrats struggled to pass only a bill to expand hospital construction, and then ceded control of Congress to the GOP the next fall. After regaining control in 1948, they tried—and failed—again. The reasons are many, but the emotionally fraught imagery of Soviet-style statism played a key part—especially when those arguments were foisted on patients in their doctors' waiting rooms, where they were handed brochures, cartoons and other material warning of the dreaded socialized medicine.
If anything should have put the socialized medicine boogeyman to rest, it was the passage of Medicare and Medicaid. By the mid-1960s, the Cold War was thawing. Arms control and superpower summitry eased tensions with the Soviet Union. Postwar prosperity had quelled most fears about the welfare state, and politicians who fulminated about communism and socialism attracted more ridicule than support. John F. Kennedy, according to Arthur M. Schlesinger's newly published journals, mocked Dwight Eisenhower for "attacking medical care for the old under Social Security as 'socialized medicine'—and then getting into his government limousine and heading out to Walter Reed." As bills to implement Medicare and Medicaid wended their way through Congress, the AMA again cautioned of the "dangerous adventure in government medicine" that would produce "mountains of red tape." But the arguments now had a tinny ring. The two plans easily passed Congress in the summer of 1965. Lyndon Johnson signed them into law at the Truman Presidential Library, with the former president at his side, beaming.
In the following years, the public seemed to demand more, not less, government involvement in guaranteeing social provisions like health insurance. Indeed, so great was this public pressure that even Richard Nixon, traditionally a champion of small government and free-market economics, found himself forced to forgo attacks on socialized medicine and to propose his own version of national health insurance instead.
Even Bill Clinton's failure to pass health-care reform suggests that the specter of statism had lost some of its political force. In 1994 the term socialized medicine was heard less often than in previous battles. One of the few who used it was Clinton, when he donned Truman's mantle to deride those critics of the former president who had stooped to use what Clinton implied was a shrill and overwroughtcharge. ("What did they say? 'Harry Truman's a radical liberal. He's for socialized medicine.' … Well, the truth is, Harry Truman … had this old-fashioned notion … that people who work hard and play by the rules ought to help one another.") To be sure, Republicans made hay with less archaic-sounding phrases such as the "government takeover of the health care system" (even though Clinton's plan relied more on market mechanisms than on government ukases). Newt Gingrich, then House minority whip, blasted Clinton's plan as a throwback to the kind of "centralized, command bureaucracies" that were dying across Eastern Europe.
But if these attacks ginned up some hostility to Clinton's plan, the real problem was more fundamental. As political scientist Jacob Hacker has argued, the basic obstacle was nothing less than the government's failure to have adopted a comprehensive health insurance plan decades earlier. As a result, the system that emerged by 1994 entailed such a crazy quilt of private interests—corporations, small firms, insurers, doctors, unions, HMOs, and so on—that moving all Americans into a new framework without worsening anyone's situation had become virtually impossible. Many of these interest groups (including doctors) actually favored reform in the abstract. But no particular plan was going to please them all.
Perhaps, then, the socialized medicine scare tactic really has run its course. The Republicans' decision to dust it off for one more battle may say more about their party's continued sprint to the right-wing extreme than about any intrinsic public hostility to government social programs. If this is the case, then Democrats might be wise to offer health-care proposals that don't upend the status quo, while brushing off the socialized medicine attacks as atavistic Cold War-era alarmism. Which seems to be, for the moment, precisely what they're doing.
The author would like to thank Jonathan Cohn, Geoffrey Nunberg, and Paul Starr for their assistance.