Harry Truman’s Healthcare Plan and Our Current Sorry State

What President Truman tried to do and where we are today, by David Oshinsky for The New York Review of Books:

“Bow your heads, folks, conservatism has hit America,” The New Republic lamented following the 1946 elections. “All the rest of the world is moving Left, America is moving Right.” Having dominated both houses of Congress throughout President Franklin Roosevelt’s three-plus terms in office (1933–1945), Democrats lost their majorities in a blowout. Some blamed it on the death of FDR, others on the emerging Soviet threat or the bumpy return to civilian life following World War II. The incoming Republican “Class of ’46” would leave a deep mark on history; its members, including California’s Richard Nixon and Wisconsin’s Joseph McCarthy, were determined to root out Reds in government and rein in the social programs of the New Deal.

One issue in particular became fodder for the Republican assault. In 1945 President Harry Truman had delivered a special message to Congress laying out a plan for national health insurance—an idea the pragmatic and immensely popular FDR had carefully skirted. As an artillery officer in World War I, Truman had been troubled by the poor health of his recruits, and as chairman of a select Senate committee to investigate the defense program during World War II, his worries had grown. More than five million draftees had been rejected as “unfit for military service,” not counting the 1.5 million discharged for medical reasons following their induction. For Truman, these numbers went beyond military preparedness; they spoke to the glaring inequities of American life. “People with low or moderate incomes do not get the same medical attention as those with high incomes,” he said. “The poor have more sickness, but they get less medical care.”

Truman proposed federal grants for hospital construction and medical research. He insisted, controversially, not only that the nation had too few doctors, but that the ones it did have were clustered in the wrong places. And he addressed the “principal reason” that forced so many Americans to forgo vital medical care: “They cannot afford to pay for it.”

The facts seemed to bear him out. Close to half the counties in the United States lacked a general hospital. Government estimates showed that about $11 million was spent annually on “new treatments and cures for disease,” as opposed to $275 million for “industrial research.” Though the nation claimed to have approximately one physician per 1,500 people, the ratio in poor and rural counties regularly dipped below one per 3,000, the so-called danger line. On average, studies showed, two thirds of the population lacked the means to meet a sustained health crisis.

The concept of government health insurance was not entirely new. A few states had toyed with instituting it, but their intent was to replace wages lost to illness or injury, not to pay the cost of medical care. Truman’s plan called for universal health insurance—unlike the Social Security Act of 1935, which excluded more than 40 percent of the nation’s labor force, mostly agricultural and domestic workers. Funded by a federal payroll tax, the plan offered full medical and dental coverage—office visits, hospitalization, tests, procedures, drugs—to all wage and salary earners and their dependents. “Needy persons and other groups” were promised equal coverage “paid for them by public agencies.”

People would be free to choose their own doctors, who in turn could participate fully, partly, or not at all in the plan. Private health insurance programs would continue to operate, with policyholders required to contribute to the federal system as well—a stipulation the president compared to a taxpayer choosing to send a child to private school. “What I am recommending is not socialized medicine,” Truman insisted. “Socialized medicine means that all doctors work as employees of government. The American people want no such system. No such system is here proposed.”

It did him no good. At the first Senate hearing on the proposal, Ohio’s Robert A. Taft, . . .  known to his admirers as “Mr. Republican,” denounced it as “the most socialistic measure that this Congress has ever had before it.” A shouting match ensued. . . . Taft retreated, but not before vowing to kill any part of the plan that reached the Senate floor.

. . .  A predictable coalition soon emerged, backed by pharmaceutical and insurance companies but directed by the American Medical Association, which levied a $25 political assessment on its members to finance the effort. At its crudest, the campaign pushed a kind of medical McCarthyism by accusing the White House of inventing ways to turn a brave, risk-taking people into a bunch of “dainty, steam-heated, rubber-tired, beauty-rested, effeminized, pampered sissies”—easy pickings for the nation’s godless cold war foe. “UN–AMERICAN SYSTEM BLUEPRINTED IN THE KREMLIN HEADQUARTERS OF THE COMMUNIST INTERNATIONALE,” read one AMA missive describing the origins of Truman’s plan.

Precious freedoms were at stake, Americans were told: when the president claimed that medical choices would remain in private hands, he was lying; federal health insurance meant government control; decisions once made by doctors and patients would become the province of faceless bureaucrats; quality would suffer and privacy would vanish. Skeptics were reminded of Lenin’s alleged remark—likely invented by an opponent of Truman’s heath plan—that socialized medicine represented “the keystone to the arch of the socialized state.”

The economist Milton Friedman once described the AMA as “perhaps the strongest trade union in the United States.” It influenced medical school curriculums, limited the number of graduates, and policed the rules for certification and practice. For the AMA, Truman’s proposal not only challenged the profession’s autonomy, it also made doctors look as if they could not be trusted to place the country’s needs above their own. As a result, the AMA ran a simultaneous campaign congratulating its members for making Americans the healthiest people in the world. The existing system worked, it claimed, because so many physicians followed the golden rule, charging patients on a sliding scale that turned almost no one away. If the patient was wealthy, the fee went up; others paid less, or nothing at all. What was better in a free society: the intrusive reach of the state or the big-hearted efforts of the medical community?

Given the stakes, the smearing of national health insurance was not unexpected. What did come as a surprise, however, was the palpable lack of support for the idea. For many Americans, the return to prosperity following World War II made Truman’s proposal seem less urgent than the sweeping initiatives that had ended the bread lines and joblessness of the Great Depression. Even the Democratic Party’s prime constituency—organized labor—showed limited interest. During the war, to compensate workers for the income lost to wage controls, Congress had passed a law that exempted health care benefits from federal taxation. Designed as a temporary measure, it proved so popular that it became a permanent part of the tax code.

Unions loved the idea of companies providing health insurance in lieu of taxable wages. It appeared to offer the average American the sort of write-off reserved for the privileged classes, and indeed it did. Current studies show that union members are far more likely to have health insurance and paid sick leave than nonunion workers in the same industry. . . .

At about the same time, popular insurance plans like Blue Cross emerged to offer cheap, prepaid hospital care . . . . In 1939 fewer than six million people carried such insurance; by 1950, that number had increased fivefold. In the years after Truman’s plan died in Congress, the government filled some of the egregious gaps in the private insurance system with expensive programs for the poor, the elderly, and others in high-risk categories, thereby cementing America’s outlier status as the world’s only advanced industrial nation without universal health care. . . .

[In the United Kingdom, the National Health Service] succeeded because the Labour Party won a landslide victory in 1945 in a country battered by war and facing a bleak economic future—precisely the opposite of the American experience. Opinion polls in the UK showed strong support for a government-run system offering universal, comprehensive, and free health care financed by general taxation. But the threat of a physicians’ strike forced Labour’s health minister, Aneurin Bevan, to scrap the idea of turning doctors into full-time government employees. . . .

The UK excels in universal coverage, simplicity of payment, and protection of low-income groups. While the NHS remains quite popular, it also is seriously underfunded: the UK ranks dead last in both health care spending per capita ($3,900) and health care spending as a percentage of gross domestic product (9.6) among the six European nations [reviewed in Ezekiel Emanuel’s book Which Country Has the World’s Best Healthcare?] The most common complaints . . .  concern staff shortages and wait times for primary care appointments, elective surgeries, and even cancer treatments . . .  “The public does not want to replace the system with an alternative,” writes Emanuel. “All the public wants is a fully operational NHS.”

By contrast, the US health care system—if one can call it that—excludes more people, provides thinner coverage, and is far less affordable. It combines socialized medicine practiced by the Department of Veterans Affairs, four-part federal Medicare (A, B, C, D) for the elderly and disabled, state-by-state Medicaid for the poor, health coverage provided by employers, and policies bought privately through an insurance agent or an Affordable Care Act exchange—all of which still leave 10 percent of the population unprotected. . . . “The United States basically has every type of health financing ever invented,” Ezekiel adds. “This is preposterous.”

And extremely expensive. America dwarfs other nations in both health care spending per capita ($10,700) and health care spending as a percentage of GDP (17.9). Hospital stays, doctor services, prescription drugs, medical devices, laboratory testing—the excesses are legion. Childbirth costs on average about $4,000 in Western Europe, where midwives are used extensively and charges are bundled together, but close to $30,000 in the US, where the patient is billed separately by specialists—radiologists, pathologists, anesthesiologists—whom she likely never meets, and where charges pile up item by item in what one recent study called a “wasteful overuse of drugs and technologies.” There is no evidence that such extravagance makes for better health care outcomes. The rates of maternal and infant death in the US are higher than in other industrialized nations, partly because the poor, minorities, and children are disproportionately uninsured.

For head-spinning price disparities, however, nothing compares to pharmaceuticals. Americans account for almost half the $1 trillion spent annually for prescription drugs worldwide, while comprising less than 5 percent of the world’s population. It is probably [i.e. definitely] no coincidence that the pharmaceutical industry spent almost twice as much on political lobbying between 1998 and 2020 as its nearest competitor, the insurance industry. . . .

Unquote.

Whenever the president is asked why he wants to eliminate the Affordable Care Act (which means people with “pre-existing conditions” would no longer be protected, among other things), he says he’s going to announce a beautiful replacement for the ACA “in two weeks”. Or “next month”. It’s always in two weeks or next month. Reporters never press him for details, because they know he’s full of crap.

Una volta un truffatore, sempre un truffatore (once a con man, always a con man).

PS:  Ezekiel Emanuel says different countries do different things very well, but if he had to choose his personal favorite, he’d pick healthcare in The Netherlands, with Germany, Norway and Taiwan in the running.

Why Japan Surrendered in 1945

It’s commonly said (in America anyway) that dropping atomic bombs on Hiroshima and Nagasaki in August 1945 saved the lives of thousands, even hundreds of thousands, of American soldiers, since our destruction of Hiroshima and Nagasaki convinced Japan to surrender, and that meant we didn’t have to invade Japan.

According to Hiroshima Nagasaki: The Real Story of the Atomic Bombings and Their Aftermath, by the Australian historian Paul Ham, that’s not how historians view those events. I haven’t read the book and don’t know if I ever will (it’s 500 pages plus notes), but a review at the Los Angeles Review of Books site by Rutgers University historian H. Bruce Franklin strongly suggests that the book is worth reading if you want to understand what really happened at the end of World War 2.

Franklin summarizes the consensus view among historians:

…the atomic bombs were not necessary and did not significantly shorten the war, … no invasion of Japan prior to November was even contemplated, … the surrender of Japan was already imminent in July, … the Soviet entry into the war on August 9 was a major factor in the Japanese surrender, and therefore the atomic bombs probably saved no American lives at all.

He also summarizes Japan’s military situation in mid-July 1945:

… Japan had lost all its bases in the Pacific, and fleets of B-29 Superfortresses had reduced all but four Japanese cities to desolate ruins and smoking ashes while carrier-based navy bombers were systematically destroying its military facilities. Japan had no viable defenses against these aerial assaults. Japan’s only remaining army of any significance was isolated in Manchuria and Korea, and could not be brought home to defend the homeland because US ships were blockading Japan and shelling its coastal regions with impunity.

The most surprising aspect of this story (speaking as someone educated in the United States) is the role of the Soviet Union in ending the war with Japan. The Russians had agreed months before to enter the war by August. The Red Army had more than one million men in position by July. On July 17th, President Truman wrote in his diary that the war would be over as soon as the Russians began their offensive. 

Then Truman received a full report on the successful testing of the atomic bomb:

Up until the time he received the full report on July 21 …, Truman and his advisors kept urging the USSR to enter the war as soon as possible. After that date, they kept trying to delay the Soviet entrance into the war. On July 26, the United States and United Kingdom issued the Potsdam Declaration, an ultimatum that demanded Japan’s “unconditional surrender” or face “prompt and utter destruction.” … As Ham and many others have argued, the demand for “unconditional surrender” effectively rebuffed the numerous Japanese attempts to negotiate a surrender, which had been going on for months.

Ham argues that the decisive event in this rapid sequence was: 

the Soviet juggernaut that destroyed Japan’s last great land army and terrified that nation’s leaders… At midnight on August eighth, the Red Army launched the largest land engagement of the entire Pacific war. Within a few days, almost 600,000 Japanese soldiers and hundreds of Japanese generals had surrendered. Eighty thousand had been killed… [The Soviet  campaign] captured from the Japanese in a week of colossal combat an area almost the size of Europe.

Before reading this review, I’d never heard of this large-scale combat between the Russians and the Japanese. As Franklin says, the story we all heard was that the Soviet Union had declared war on Japan after the atom bombs went off in order to join in the victory. America had already finished the job. But according to Ham:

A greater threat than nuclear weapons — in Tokyo’s eyes — drove Japan finally to accept the surrender: the regime’s suffocating fear of Russia. The Soviet invasion of August 8 crushed the Kwantung Army’s frontline units within days, and sent a crippling loss of confidence across Tokyo. The Japanese warlords despaired. Their erstwhile “neutral” partner had turned into their worst nightmare. The invasion invoked the spectre of a communist Japan, no less.

According to Ham, the bombing of Hiroshima and Nagasaki didn’t make much of an impression on the Japanese leadership. The firebombing of other Japanese cities, especially Tokyo, had already demonstrated our ability to destroy cities and kill civilians. Some of the Japanese leadership had already been advocating for peace. Franklin and Ham describe what happened next: 

An hour before the atomic bomb fell on Nagasaki, the war and peace factions of cabinet met in a bomb shelter under the Imperial Palace and began a furious and endless debate about the terms of surrender they should offer because of the Soviet invasion of Manchuria… Ham describes how they greeted the news of Nagasaki:

“Nothing of great moment had occurred in Hiroshima to persuade them of the futility of further defiance; the militarists scorned the weapon as a cowardly attack on defenceless civilians. Toward the end of the interminable discussion — now into its third hour — a messenger arrived with the news of the destruction of Nagasaki — by another ‘special bomb’. The [Japanese leaders] paused, registered the news, and resumed their earlier conversation. The messenger, bowing apologetically, was sent on his way. ‘No record … treated the effect [of the Nagasaki bomb] seriously,” noted the official history of the Imperial General Headquarters’.

The doves in the Japanese leadership had been demanding that the Emperor remain in power after a Japanese surrender. That was the single condition they had insisted on. Now the hawks agreed. Japan would surrender so long as the Emperor’s position would be maintained. The U.S., which had previously insisted on unconditional surrender, finally conceded that the Emperor would remain in power. The war was over. 

Given this evidence, it’s clear that the Soviet Union played an important role in ending the War in the Pacific. The stories about Soviet opportunism are clearly false (they had, after all, been carrying the brunt of the war again Germany earlier in 1945). Whether Truman should have dropped the bomb is another question. The most charitable interpretation is that he truly believed using the bomb would significantly shorten the war and save lives (not just American lives but Japanese and Russian lives?). A less charitable interpretation is that his real target was the Soviet Union. Using the bomb against Japan showed the Russians that America had the most powerful weapon in the world and was willing to use it. It also resulted in the Soviet Union controlling less of East Asia when the war ended and America controlling more. He probably had all these considerations in mind before he ordered the incineration of Hiroshima and Nagasaki.