State of the Union and Healthcare: 100 Years of Good Intentions

The following slideshow tells the very long, difficult story that defines American healthcare through 70 years of presidential State of the Union addresses, with a final bow to an earlier president. Beginning with FDR's address, every US president (with one exception), whether Democrat or Republican, has communicated during a State of the Union address a proposal for improving the nation's health. The purpose of this slideshow is not to debate whether such programs were achieved or are even achievable but to briefly illustrate the typically good -- but usually thwarted -- intentions of nearly all of our recent presidents and to demonstrate how long the Executive Office has wrestled with this massive challenge.

Franklin D. Roosevelt (1933-1945): Healthcare Is a Right

In his 1944 address, FDR announced "...a second Bill of Rights under which a new basis of security and prosperity can be established for all regardless of station, race, or creed." Among these rights he included employment, housing, and good education. He also spoke of "the right to adequate medical care and the opportunity to achieve and enjoy good health." Public health had been a major federal effort since Theodore Roosevelt's administration, but with this proposal FDR became the first president to explicitly suggest that medical care itself was a right for each American and should be addressed by the federal government.

Harry S. Truman (1945-1953): Advocates a National Healthcare System

During his administration, Harry Truman consistently advocated a national healthcare system, and it was during his time in office that Congress enacted new programs to improve mental health, the health of mothers and children, and hospital construction. In his 1948 State of the Union address, Truman said, "We are rightly proud of the high standards of medical care we know how to provide in the United States. The fact is, however, that most of our people cannot afford to pay for the care they need." He went on to advocate a "national system of payment for medical care based on well-tried insurance principles. This great Nation cannot afford to allow its citizens to suffer needlessly from the lack of proper medical care. Our ultimate aim must be a comprehensive insurance system to protect all our people equally against insecurity and ill health."

Dwight D. Eisenhower (1953-1961): Establishes the Department of Health, Education, and Welfare

Dwight Eisenhower continued to advocate for a more comprehensive national plan for healthcare. In his 1956 State of the Union address, he said, "We must aid in cushioning the heavy and rising costs of illness and hospitalization to individuals and families. Provision should be made, by Federal reinsurance or otherwise, to foster extension of voluntary health insurance coverage to many more persons, especially older persons and those in rural areas. Plans should be evolved to improve protection against the costs of prolonged or severe illness. These measures will help reduce the dollar barrier between many Americans and the benefits of modern medical care." Although such efforts failed to materialize over the course of Eisenhower's time in office, he strengthened the US Food and Drug Administration and increased funds for medical research.

John F. Kennedy (1961-1963): Calls for Healthcare for the Elderly

Fifty years ago, in his 1961 State of the Union address, Kennedy said, "Medical research has achieved new wonders -- but these wonders are too often beyond the reach of too many people, owing to a lack of income (particularly among the aged), a lack of hospital beds, a lack of nursing homes and a lack of doctors and dentists. Measures to provide healthcare for the aged under Social Security, and to increase the supply of both facilities and personnel, must be undertaken..." And he continued to advocate reform in his final address: "Our working men and women, instead of being forced to beg for help from public charity once they are old and ill, should start contributing now to their own retirement health program through the Social Security System."

Lyndon B. Johnson (1963-1969): Enacts Medicare/Medicaid

It was in 1965, under Lyndon Johnson's administration, that Social Security Act amendments were passed which resulted in the creation of the Medicare and Medicaid programs. Although snarled in Vietnam, Johnson made a case for health reform in his 1967 State of the Union address: "We have brought medical care to older people who were unable to afford it. Three and one-half million Americans have already received treatment under Medicare since July." He also sought to improve global health in his 1966 address: "I will also propose the International Health Act of 1966 to strike at disease by a new effort to bring modern skills and knowledge to the uncared-for, those suffering in the world, and by trying to wipe out smallpox and malaria and control yellow fever over most of the world during this next decade." (This bill was never enacted.)

Richard M. Nixon (1969-1974): An Unexpected Reformer

Although not known for a stand on healthcare reform, in his 1971 address, Richard Nixon, a Republican, proposed major reforms that are echoed in today's Affordable Care Act, including the following:

• A program to ensure that no American family will be prevented from obtaining basic medical care by inability to pay;

• A major increase in aid to medical schools;

• Incentives to improve the delivery of health services, particularly in low-resource areas;

• Greater use of medical assistants;

• New programs to encourage better preventive medicine;

• Incentives to doctors "to keep people well rather than just to treat them when they are sick"; and

• An additional $100 million to find a cure for cancer.

During his address he asserted, "America has long been the wealthiest nation in the world. Now it is time we became the healthiest nation in the world."

Gerald R. Ford (1974-1977): Confronts the Growing Costs of Healthcare

Gerald Ford, who inherited the presidency after Nixon's resignation, wrestled with the problems of illness and individual financial hardship in the face of rising healthcare costs, not only for patients but for the nation as well. In his 1976 address, Ford sought to deal with these issues by proposing "catastrophic health insurance for everybody covered by Medicare." To finance it, he suggested raising fees for short-term care and lowering costs for senior citizens: "[N]obody after reaching age 65 will have to pay more than $500 a year for covered hospital or nursing home care, nor more than $250 for 1 year's doctor bills." But Ford also made clear in his speech that he did not support a national healthcare program, although he suggested that "we combine 16 existing Federal programs, including Medicaid, into a single $10 billion Federal grant. Funds would be divided among States under a new formula which provides a larger share of Federal money to those States that have a larger share of low-income families."

James "Jimmy" Carter (1977-1981): Pushes Harder for Universal Healthcare Coverage

In his 1981 address, Jimmy Carter pushed even harder than his predecessors "to reach the goal of comprehensive, universal healthcare coverage." Features that he proposed included:

• Fully subsidized and comprehensive coverage for 15 million additional poor persons;

• Prenatal and delivery services for all pregnant women and coverage for all acute care for infants in their first year of life;

• A limit of $1250 on annual out-of-pocket medical expenses and no limits on hospital coverage for the elderly and disabled;

• Mandated employer coverage of health insurance for all full-time employees and their families, at least for major medical expenses; and

• Medicare and Medicaid combined and expanded into an umbrella federal program.

His proposals for healthcare cost control included voluntary hospital cost guidelines and moving away from the fee-for-service payment model "toward a system of prospective reimbursement, under which healthcare providers would operate within predetermined budgets."

Ronald W. Reagan (1981-1989): Ignores Healthcare Reform and Focuses on Cost

Ronald Reagan raised the issue of healthcare in 3 of his 8 addresses, but only briefly, and mostly focused on cost cutting, without detailing any programs for extending coverage. His 1982 speech urged a need to reduce Medicare and Medicaid costs, with a focus on weeding out fraud. He also said, "I signed a bill to reduce the growth of these programs by $44 billion over the next 3 years while at the same time preserving essential services for the truly needy." In 2 other addresses, Reagan briefly acknowledged the problem of catastrophic illness but without outlining any specific ideas. In his 1983 address, he said he would "submit legislation to provide catastrophic illness insurance coverage for older Americans." And in his 1986 speech, he directed the Secretary of Health and Human Services to recommend how the private sector and government could work together to address the problems of affordable insurance for those threatened with financially catastrophic illness.

George H. W. Bush (1989-1993): Re-Engages the Healthcare Reform Battle

The elder George Bush mentioned healthcare as a problem in 2 of his early speeches, and he tackled the issue in more detail in his last address, which was in 1992. Recognizing the need for reform, he said that there were 2 options: implementing a national healthcare system, which he opposed, or providing insurance security for everyone while preserving choice. To accomplish this, he proposed to make basic health insurance affordable for all low-income persons who were not currently covered by providing a health insurance tax credit of up to $3750 for each family, and to ensure that all Americans had access to basic health insurance even if they changed jobs or developed serious health problems.

William J. Clinton (1993-2001): The Attack Dog for Healthcare Reform

The movement toward true healthcare reform began under Bill Clinton, who proposed significant changes in the healthcare system in every one of his presidential addresses. Despite Hillary Clinton's failure to achieve consensus on an enactable healthcare plan, Clinton pushed on. In his 1995 address, he said, "[L]ast year we almost came to blows over healthcare, but we didn't do anything...Let's do whatever we have to do to get something done. Let's at least pass meaningful insurance reform." Congress did extend health coverage to 5 million children, and Clinton ended his administration with a budget surplus, which he hoped would ensure the future of big entitlement programs like Social Security. In his 1999 address, he proposed, "Listen to this: If we set aside 60% of the surplus for Social Security and 16% for Medicare, over the next 15 years, that saving will achieve the lowest level of publicly held debt since right before World War I, in 1917."

George W. Bush (2001-2009): Keeps the Healthcare Debate Alive

George W. Bush may have had his hands full with preventing terrorism and ongoing wars in Afghanistan and Iraq, but he continued the discussion on healthcare in every presidential address with some very aggressive proposals. In his 2005 address, he urged Congress "to move forward on a comprehensive healthcare agenda with tax credits to help low-income workers buy insurance, a community health center in every poor county, improved information technology, association health plans for small businesses and their employees, expanded health savings accounts, and medical liability reform that will reduce healthcare costs and make sure patients have the doctors and care they need." He expanded on these ideas in later addresses and continued to push for major changes in healthcare.

Barack H. Obama (2009-Present): Creating Change

Barack Obama has taken ideas from every past president -- Republican and Democrat -- to try to create a solution to the American healthcare challenge. His signing of the Affordable Care Act has been criticized by the left for not going far enough and by the right for going too far. In his 2011 address, he summed up the current situation: "Now, I have heard rumors that a few of you still have concerns about our new healthcare law. So let me be the first to say that anything can be improved. If you have ideas about how to improve this law by making care better or more affordable, I am eager to work with you...What I'm not willing to do is go back to the days when insurance companies could deny someone coverage because of a preexisting condition...So I say to this chamber tonight: Instead of refighting the battles of the last 2 years, let's fix what needs fixing, and let's move forward."

Theodore Roosevelt (1901-1909): The Origins of National Healthcare

We must go back more than 100 years to Theodore Roosevelt's administration to find the nidus of national healthcare. In his 1907 address, he said, "There is a constantly growing interest in this country in the question of the public health. At last the public mind is awake to the fact that many diseases, notably tuberculosis, are National scourges. The work of the State and city boards of health should be supplemented by a constantly increasing interest on the part of the National Government. The Congress has already provided a bureau of public health and has provided for a hygienic laboratory. There are other valuable laws relating to the public health connected with the various departments. This whole branch of the Government should be strengthened and aided in every way."

Photo Credits: Wikimedia/Wiki Commons