- Inching Toward Universal Coverage:State-Federal Health-Care Programs in Historical Perspective
Much has been written in the popular press and academic journals about the Affordable Care Act (ACA). It has been characterized by its supporters as the biggest expansion of coverage since the Great Society, and by its detractors as government overreach and socialism. Even after the president’s signature, two major Supreme Court verdicts upholding essential features, and the president’s reelection, political opposition to the ACA, almost exclusively confined to Republicans, has shown few signs of abating. Unfortunately, the often shallow public debate about the ACA largely ignores the historical context of the American grant-in-aid system, its evolutionary nature, and its crucial role in expanding access to health care. We seek to remedy this lack of context by providing an overview of the development of the U.S. grant system, focused on health-care-related programs, from the earliest days of the Republic to the ACA. We argue that much of relevance to understanding the current controversy and predicting how it will play out over time can be learned from this history. It follows a large number of works assessing the development of the American welfare state.1 However, it significantly differs from previous works by focusing exclusively on programs of shared governance; that is, programs jointly implemented and administered by federal and state governments. Additionally, it differs in its emphasis by exclusively focusing on health-care-related programs.
Based on our analysis, we challenge the ubiquitous claims that the ACA is a cataclysmic departure from everything that came before it. Instead, we argue [End Page 746] that within the American grant system, particularly as it has been used to expand access to health care, the ACA should be seen as a very substantial, but nonetheless natural, continuation of a long series of incremental, trial-and-error adjustments to new circumstances. Lacking the constitutional power to force states into action, the federal government necessarily seeks to entice states into cooperation through financial incentives.2 Not surprisingly, when given latitude, states have often implemented programs only slowly and gradually—and sometimes not all.3 However, over time, the federal government and the states usually become partners who share in the development, design, administration, and improvement of these programs. Within this system, earlier programs serve as foundations for future expansions. In the process of this transformation, grant programs have expanded in number, size, subject matter, and the extent of administrative involvement by the federal government. These developments have been neither consciously rational nor synoptic. Instead, they should be seen as the result of successive adaptations to altered circumstances.
We proceed as follows. First, we present a brief overview of the development of the American grant system from the early days of the Republic to the first true health-related grant of significance, the Sheppard-Towner Act of 1921. We show how over time a system of monetary and land grants incrementally increased in size and purpose. However, the early system was largely free from federal interference and focused on providing states with funding for generally uncontroversial programs. Over time, changing economic, social, and demographic circumstances necessitated expansion of the system in terms of subject matter and type of grants. Second, we trace the development of major health-care-related grants. We begin with the developments leading up to the Sheppard-Towner Act. Next, we consider efforts during the Depression and World War II, followed by programs in the postwar period up to the Great Society. Finally, we turn to more recent programs, including Disproportionate Share Hospital Funding (DSH), the Health Insurance Portability and Accountability Act of 1996 (HIPAA), the State Children’s Health Insurance Program (S-CHIP), and the Trade Act of 2002. We do so by providing brief accounts of the key features of each program. While much has been written about several of these programs independently, we argue that much more can be gained by taking a more holistic and historical view. We conclude by summarizing the contributions of past programs to the ACA and by offering an outlook for its future. [End Page 747]