Body Politics

A History of Health Care

In 1912, Teddy Roosevelt became the first presidential candidate to stump for national health insurance. He lost that election, but a century later, the issue continues to divide Americans.

On this episode, the Backstory hosts explore the origins of the health care debate, and try to explain how we wound up with a system so different from the European model. They hear from Jacob Hacker, author of the “public option” plan, about why lobbyists hold so much sway over health policy, and travel back to 1611 to visit colonial America’s first hospital. They also hear the story of how inoculation first came to the New World.

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[RUSH TRANSCRIPT – Uncorrected Proof]
Peter:  This is BackStory with us, the American Backstory hosts.  I’m Peter Onuf, 18th century guy.

Ed:  I’m Ed Ayers, 19th century guy.

Brian:  And I’m Brian Balogh, 20th century history guy.

[Recording of Harry Truman] “In a nation as rich as ours, it is a shocking fact that tens of millions lack adequate medical care.”

Brian:  That’s Harry Truman in his State of the Union Address to Congress in 1949.  He had just been re-elected.  Maybe that’s why he decided to drag out this old agenda item which so far had gone absolutely nowhere.

[Recording of Harry Truman] “Moreover, we need and we must have without further delay a system of prepaid medical insurance, which will enable every American to afford good medical care.”

Ed:  And needless to say, we did have further delay – 60 years of it in fact, and still counting, and it’s not for lack of trying.  Truman may have been the first President with a concrete proposal for universal health insurance, but there have been plenty more since then:  Lyndon Johnson, Richard Nixon, and most recently, Bill Clinton.  So can President Obama accomplish now what so many other presidents have failed to do.

Peter:  On each episode of BackStory, we pluck a topic from the headlines and spend an hour exploring its history.  Today, that topic is health care.  How has the debate played out since Truman, and what did it look like before him?  Was access to health care such an issue before the age of modern medicine.

Brian:  When we started fielding health care questions on our web site a few weeks ago, it quickly became apparent that there was one question that was on everybody’s minds:  It was summed up nicely on this voice mail from a listener in Ohio.

Caller Bruce: “Hi, this is Bruce Weingard, I’m calling from Columbus, Ohio.  I have a question regarding how is it that the American approach to health care differs so from the European model.  Where did we go in a different route.”

Ed:  So I guess the question is, when did American and European systems of health care diverge.  Did it happen back in ye olden times, Peter?

Peter:  Well, Ed, I think using the word “system” is overdoing it a little bit for the Colonial period, and basically, as you know, there were no public institutions to speak of.  It’s only in Colonial cities that you  have poor houses and jails and eventually, a hospital in Philadelphia in 1751.  But that’s unusual, most Colonial Americans deal with the issue of life and death within the family.

Ed:  Would that have been very different back in Europe?

Peter:  No, honestly, the big difference is a question of scale. When you have a large number of people in a big city, they’re often not connected with each other, so the family form simply doesn’t exist, and there are institutions that make up for the failure of families, but that’s not health care.  It’s more getting dead bodies out of the way, burying them. . . that’s pretty brutal.

Ed:  Well, 19th century think that maybe there were great advances in technology.

Peter:  Yeah, which ones would those be?

Ed:  . . . but there weren’t.  Not until the very end of the 19th century, which comes perilously close to edging into Brian’s territory.

Peter:  So should we just give the whole show up to Brian?  What do you say.

Ed:  Well, you know, I was trying to kill as much time as possible by talking about things that didn’t happen in our centuries.

Brian:  You mean, I actually get to answer a question?  This could be a first on BackStory.

Ed:  Too bad you wasted part of your time talking about how you finally get to answer one.

Brian:  And now I’ve got to waste more of it because, in fact, I want to turn to this other guy, who’s going to answer part of that question first.

Jacob Hacker: My name is Jacob Hacker, I’m a Professor of Political Science at Yale University.

Brian:  I should tell you right now that Jacob Hacker, he’s not just any political scientist.  This is the guy who, as a grad student 10 years ago, basically created the blueprint of this public option that we’ve been hearing so much about.  So it’s clear where he stands in the legislative debate, but still, I thought it would be interesting to get his take on some of the history.  So I put our caller’s question to him.

Jacob Hacker: Well, there’s a couple of answer to that question.  The political scientist in me will say this is a reflection of our fragmented political institutions, and our anti-government political culture, that’s sort of one class of explanation.

Brian:  Hold up, time out, Mr. Political Scientist.  What do you mean by fragmented institutions.  In radio talk, what is that?

Jacob Hacker: Well, in radio talk, it’s the checks and balances that our Constitution creates that make it so hard to pass integrated comprehensive programs.

Brian:  So different branches of government.

Jacob Hacker: Different branches of government, federalism with the states and the federal government with overlapping responsibilities.  There’s been scores of Europeans who have come over to the United States and sniffed at the American state, and said it doesn’t really constitute a state at all because it is so messy, and it is generally very hard to pass big legislative initiatives.

Brian:  So that’s the political science view on all of this.  It wasn’t simply doctors or drug companies who are opposed to reform.  And it wasn’t just the big, bad insurance companies either.  Hacker says that all those business interests would not have had the impact they had if it weren’t for our decentralized model of government.

Jacob Hacker: But I think it’s really important to understand that every time we’ve failed in the past to enact reform, a new set of vested interests has emerged, and just as important, we’ve seen the development of a massive system of private health insurance that covers the vast majority of working Americans.  So to me that’s the big story, that the choices we made in the past have sent us down a path that’s very hard to get off of.

Brian:  Health reform, on the national level, first went down for defeat in the Progressive Era, back in 1912.  That was the year that Teddy Roosevelt ran unsuccessfully for a third term on a populist platform, that included compulsory sickness insurance, that would cover people’s wages while they were sick and out of work.  The fight then moved to the state level, and reformers came close to winning in both New York and California.  But this was just about the time that doctors were really beginning to feel their oats and organize, and medical care was getting more expensive.  It didn’t take those doctors long to figure out that health care reform might directly affect their livelihoods.  And then, there were these brand new insurance companies.  Here’s Hacker again.

Jacob Hacker: Perhaps what’s an interesting story from this period is the story of Frederick Hoffman who worked for Prudential, who was an actuary.  Actuaries are definitely a rabble-rousing bunch.  In any case, he turned out to be one; he probably was the leading propagandist against any of these efforts.  He said that there would be rationing of care; that government would come between patients and their doctors; he said that this was imported from Germany; that it was a Socialist plot.  He said that it would be allowing immigrants to receive care; that it would be helping the less well-bred stock of the nation, and hurting the genetically pure.  It was a panoply of fabrications and incendiary lies that bears, I’m sorry to say, a more than a passing resemblance to the some of the invective that has been hurled against health care reform this time around.  I think it’s worth remembering:  Every time we’ve had a debate over this issue, it has become a very emotional debate very quickly.

Brian:  That highly charged history probably goes a long way towards explaining why Franklin Roosevelt decided to drop national health insurance from his New Deal legislation in the mid-30s.  He had plenty on his plate already with social security and unemployment insurance, but still, it’s a decision that pains Jacob Hacker even today.

Jacob Hacker: He had a remarkable political position.  He comes into office during the worst economic downturn in the Nation’s history; he has a mandate to act; he has huge democratic majorities.  My read of the history, and a lot of other people’s read of the history, is that had Roosevelt had insisted on some kind of health insurance provision in the Social Security Act, it probably would have passed.  And he didn’t for two reasons:  one of which is the doctors were completely opposed . . .

Brian:  . . . and we should just pause and say that these were pretty big men around town, they were pretty influential in local communities, congressional districts.

Jacob Hacker:. . . yes, they had all these state chapters and local chapters, and plus, whenever you went to your doctor, they would tell you whether or not it was a good or bad thing to have this happen.

Brian:  And you know what else, we actually believed in experts in those days.  We thought they were they were the good guys.

Jacob Hacker: You’re right.  Why else would the tobacco companies have had the doctors touting Camel cigarettes, because if you’re doctor smokes, they must be good for you.  In any case, the second thing is that Roosevelt believed that he could just come back and do this a few years later.  And that was the first and the last in a sense time that putting it off was final.

Brian:  Why was FDR our last chance, as you see it, up till now?

Jacob Hacker: I think FDR was our last chance because of the fact that when reform went down to defeat in 1935, or never even got a chance to be considered, that was really a turning point in the development of private insurance.  It’s hard to remember today when people are losing coverage right and left, just how quickly health insurance expanded during and after WWII.  Blue Cross plans, hospital plans, emerged in the midst of the Depression; and by the end of WWII, we’re talking about coverage that’s probably reaching about half of the American population, and so the typical blue-collar worker before WWII, didn’t have health insurance coverage; the typical blue-collar worker after WWII had pretty generous private health insurance.  For that worker, suddenly the prospect of tax-funded national health insurance program is just a lot less attractive.  So what I think is important to understand, is that it wasn’t just private insurance companies or drug companies or businesses that benefited from relying on private health insurance, at least initially, but also lots of Americans saw private health insurance as a good solution for them.

Brian:  That’s Jacob Hacker, Political Science Professor at Yale University, and the original author of the so-called, Public Option Plan for Government Sponsored Health Insurance.

Ed:  So, the train of health care reform doesn’t stop in the Progressive era; doesn’t stop in the New Deal; barely pauses in post-WWII; slows down long enough to pick up the very poorest of Medicare and Medicaid in the 1962; but what happens in the 70s and 80s, does the idea just go underground, or are people fighting for it or what?

Brian:  No, it doesn’t go underground, and just to, I love your metaphor of the train of health care reform, but running on a separate track, and ultimately, heading for a collision after it gains enough momentum, is another train and that’s the train of health care provision.  It is stopping at every local stop, picking up those employer-based health care folks, picking up a huge number of passengers through the Veterans Administration, picking up folks through Blue Cross/Blue Shield, who are self-employed . . .

Peter:  . . . and so, Brian, would you say then that the actual tipping point that led to the current debate was that the train is beginning to empty out and a lot of people aren’t getting on.

Brian:  Yes, absolutely.  I’d say the train is derailed, Peter.  We don’t have to look at this incrementally.  Every time we run into a recession, we shed jobs, and with those jobs, goes health care.  But what’s more, starting with Nixon, this country started shedding manufacturing jobs, jobs started going overseas, and what did employers do to become more competitive and cut costs.  They started cutting their health care benefits.  So, more and more jobs don’t come with health care benefits, and that is the train wreck for the existing system.

Ed:  Well, on that chipper note, it’s time for a short break.  When we get back, we’ll talk more about the history of health care in America.  And when I say history, I mean history.  Enough of this 20th century business.

Peter:  We’d love to hear what you think the past has to teach us about the state of health care today.   Leave us a comment at  We’ll be back in a minute.


Peter:  We’re back with BackStory, the links to the past with the America of today.   I’m Peter Onuf, your guide to the 18th century.

Ed:  I’m Ed Ayers, you’re guide to the 19th century.

Brian:  And I’m Brian Balogh, guide to the 20th century.  We’re talking today about the history of health care in America.  In the first part of the show, we focused on my century, some of the background of the debate taking place now in Washington, but now it’s time for some deep history.  And when I say deep, I’m not talking about the 19th century, Ed.  I’m not even talking about the 18th century.  No, we are going all the way back to the 17th century.  I didn’t know I could count that low.

Peter:  When we think of hospitals today, we think of sick people, but back in Medieval Europe, that’s even before the 17th century, hospitals took in pilgrims, travelers, and strangers, anybody in need with no place else to go.  It’s no coincidence that hospital sounds a lot like hospitality, both share the Latin root “host space”; host for guests or strangers; and so for hundreds of years, the word hospital was used interchangeably with guest house.  Such was the case in the early 1600s when English Colonists established North America’s first hospital, right here in Virginia.  BackStory producer, Catherine Moore, has the story.

Catherine Moore:  So you’ve heard of Jamestown, but you might not have heard of Henricus, the second English settlement in the New World.  By 1611, it’s turning out that swampy, mosquito-infested Jamestown isn’t the healthiest place to make a new world, so the Virginia Company’s Deputy Governor, a military man named Sir Thomas Dale, sets his sites on a more secure spot, with fresher air.  Across the river from the new town, he builds a string of forts, one of which also serves as a place for sick people.

John Pagano: “We are in the recreation of Mt. Molado, the first English hospital or guest house built here in the New World” . . .

Catherine Moore:  I’m standing inside a large wattle and daub-style building.  As my eyes adjust to the darkness, I see a few dozen beds and tables covered with ominous looking medical instruments, herbs and suspicious powders.  My tour guide is John Pagano, an interpreter at Henricus Historical Park, who dresses as one of Sir Thomas Dale’s soldiers.  It was these soldiers who provided most of the care for the guests at Mt. Malado.

John Pagano: As part of your agreement, your indenture with the Virginia Company of London that they’ll care for you when you’re ill; they’ll provide food, clothing, shelter, all of it.

Catherine Moore:  The Virginia Company, of course, had an interest in keeping its workers healthy, and  the indentured folks back home that the New World was worth the trip.  But John tells me there was also a larger vision network.

John Pagano: Sir Thomas Dale’s going to name this area the Commonwealth, because Dale believed that everyone, whether you’re wealthy or whether you’re here as an indenture and you’re from a poor family, that everybody here pitches in to everyone’s else’s work, and everyone will prosper.  He probably, if you were to continue that thought into all areas of settlement, he might have called the medical practices here in the hospitals the common health, because no matter what class you were, you got the same treatment as everyone else.

Catherine Moore:  Sounds pretty nice.  Well, yeah, until you consider the kind of medical treatment that was liberally dispensed across class lines.

John Pagano: There is a surgeon or two in the Colony, but they’re essentially traveling surgeons, for what they called back then ‘barber surgeons’, they can cut your hair and treat your illness all at the same time.  But they don’t really have a lot to go on, so they’ll just go in, and they’ll cut around things, pull things out and look at them, and in this time period, there was no anesthesia, so this isn’t a time period where you want them to go internally into you.

Catherine Moore:  Especially when the barber surgeon is stuck down river, and all you get is the soldier with a bone saw.  You can understand why people might have been a bit hesitant to check into this guest house, after all, where the sick were cared for by women, at home.

John Pagano: The common people back then were just touching on this idea of going some place and letting someone else care for my mother or my son.  If you think about people today, would anyone go into a strange house and have someone who has no medical training work on them.

Catherine Moore:  So how would they have gone about trying to convince people that this was safe or the best way to get the care that they needed.

John Pagano: It’s such a loaded answer, because we’re going to tell you what to do and you’re going to learn to like it, because we’re the ones in charge, and although you don’t understand the wisdom of why the Virginia Company of London has this, I do.

Catherine Moore:  So before you get all misty eyed about common health and Commonwealth, remember that back then, health care was enforced at the end of a stick, so it’s little surprise that as business in the New World starts to pick up and marshall law is relaxed, Mt. Malado becomes a thing of the past.  By 1622, Thomas Dale is gone; he succumbed to the bloody flux in India, and the building has been bought by an ironmonger, who probably used it to house his workers, and we don’t see another public hospital in American for over 100 years.  In the meantime, there were a few alms houses for the poor, pest houses for serious epidemics, and itinerant doctors for the very wealthy.  But most importantly, there were more families.  Early Americans looked after their own.  Only strangers to a New World needed other strangers to take care of them.

Ed:  That’s BackStory producer, Catharine Moore.  You can see pictures of the Henricus Hospital at our website,

Brian:  So now we’re going to jump ahead in time a hundred years and travel up the East Coast to Boston.  In April of 1721, some sailors stepped off a ship from the West Indies there with a disease no one had seen in the area for 20 years, small pox.  One of the sailors was quarantined instantly, but a couple of others went into town and behaved, well, like sailors behave when their on leave.  The disease spread like wild fire, and soon the people of Boston began dying.  Reporter Nate DiMeo is going to pick up the story from here.

Nate DiMeo: It felt like the flu; you get a fever and chills, you’d feel achy, sometimes you’d throw up, sometimes you wouldn’t, and then the rash would start to appear, and you would know you were probably going to die.  In the Summer of 1721, nearly half of Boston’s 11,000 people came down with small pox.  Every other Bostonian, every other wheelwright and cooper, every other brewer, and clergymen.  And when they got it, they either died or were permanently disfigured; those were your options.  And the people of Boston were terrified, which of their loved ones would be next; which of  their customers or employees would stop showing up; would their father make it through the night; and who could they blame.  This was the Puritan city, so, of course, there was Satan, there was always Satan.  But a lot of Bostonians blame themselves; they had allowed their city to become a den of sin.  They had profited from the booming trade that was flowing in and out of it.  The broadened heathens of run and tobacco, and now this small pox.  This was God’s will.  The city should sit and take its punishment, and let the disease run its course.  Nearly every Bostonian believed it.  Nearly every doctor and clergymen believed it.  But two did not.  No one in the New World deserved more credit or more blame for making people believe it, The Reverend Cotton Mather.  Since graduating from Harvard at 15, he had written theological treatises that had defined the Puritans themselves.  He had written on the wages of sin, on the ways of demons and witches.  He helped infuse the fanatics of Salem with the belief that drove them to persecute and kill their neighbors.  But this man of God was also a man of science.  Mather had heard years before about the practice of inoculation.  A slave had told them about how back in Africa, they would take needles and remove puss from the wounds and sores of infected people, and poke it into the skin of healthy ones.  The healthy people would get sick, but for a brief time, and they wouldn’t die.  Now with smallpox spreading fear and death in his city, Mather wanted to try the heathen science.  His city wasn’t having any of it.  His fellow clergymen condemned him for heresy.  Doctors condemned him too; no doctor would sicken someone intentionally; it was against the whole point of being a doctor.  Mather showed them accounts of the Chinese doing it; of Turks doing it, but he couldn’t convince them.  The procedure was forbidden before it could even be attempted.  But one doctor decided Mather was right.  His name, his delightfully preposterous ye olde New England name was Zabdiel Boylston, and he was just as frightened as anyone else.  He had been helpless watching his patients die; seeing faces he loved become scarred and barely recognizable.  On September 21, he took a needle and scraped puss from the open sores of an infected man, and he took that needed covered in this stuff, that even in this time, long before people understood what germs were, he had to know that stuff was filled with disease;  he took that needle with one hand and with his other hand, he took his 6-year old son, held him tightly, and stabbed the needle into the boy’s arm.  Later that day, he did the same to his slave, and the slave’s own young son.  The city exploded.  Ministers, doctors, and pamphleteers condemned the two men.  They said Zabdiel Boylston was killing his son; that even by simply attempting to fend off the disease, he was defying God.  A firebomb crashed through Mather’s window; Boylston couldn’t even leave his house; even after his son and his slave, and that man’s son became better, even as other people refusing to sit and wait to die, sneaked into the doctor’s home and demanded to be inoculated, even as word spread that the procedure seemed to be working, everyone condemned the doctor and Reverend.  Later that Fall when the smallpox epidemic had finally run its course, people could finally look at the numbers.  Nearly half the city had contracted the disease; of those who had, nearly 1 in 6 had died.  Of the 244 people Boylston inoculated, 6 people died; that’s only 1 in 40.  Still, for years, much of Boston condemned Mather and Boylston, even after the next year with the British Royal Family essentially risked everything and inoculated the young heirs to the thrown.  Even after Boylston himself traveled to London to be inducted into Royal society; and even after he returned to Boston to live, and to outlive just about everyone, dying peacefully at the age of 90.

Ed:  That’s Nate DiMeo.  You can listen to more of his evocative tales about the dark corners of American history at his website,, and you can find his podcast, along with ours, in the history section of the I-tunes store.

Peter:  Well, Ed, I thought those were a couple of interesting features and they do point to something I think is really important for the larger show that we’re doing today, and that has to do with the way in the early period, and my period of the 17th and 18th century, that leaders of the community had to address public health issues, dangerous to the health of the entire community.  When they were attacked by smallpox, it was something like being attacked by a foreign enemy.  So that idea that we consider the health of the people in the context of the fate of the Commonwealth, politics, economy, and society are all so closely linked, it’s not the kind of focus on the individual, and the health of the individual that’s characteristic today.

Brian:  So is this the beginning of public health in America?

Peter:  I think that’s fair to say.  This collective strategies are necessary, and one of the reasons for this is that the prospects of dying are much greater than they are now.  I think that’s the single fact we have to keep in mind.  Women were prone to dying in childbirth; they called really old people in New England like 70 years old or 60 years old, they were revered almost as angels; they were special people because somehow God intended them to survive.  In other words, the normal expectation is death, and that means that you can’t rely on families alone.  Families have to be knit to other families, and to a broader sense of Commonwealth.

Brian:  Well, as we do with each episode of the show, we’ve been fielding comments on today’s topic at  Our producers have invited a few of the folks who’ve left comments there to join us on the phone now.

[telephone music]

Peter:  We got a call.  It’s Kathy from Athol, Massachusetts.  Welcome to the show.  We’re talking about health care, a subject that’s on everybody’s mind, and you’ve got a question.

Caller Kathy:  Hi.  I do.  I’ve been wondering whether when government got into other things that we now think of as public sectors, like public safety or public education, and I know there have been debates about public utilities back and forth, but I’m just wondering whether the health care debate is actually, sort of in a class by itself in terms of the kind of fear and anxiety that it seems to promote in people about the role of the government getting into this sort of intimate realm of life; or whether it’s really part of a long sequence of fights that are essentially over the same thing.

Peter:  Well, my reflex reaction, and that’s about what I’m good for, is to suggest that anti-state-ism and that hostility to the public sector, has become a major idealogical strain in American history, and present, from the founding.  It takes different forms, but the fear of gun control, or fluoridation of the water supply, or whatever it might be, or taxes, just about anything.  Brian, do you think this is the case in the 20th century.

Brian:  I would say that yes, anti-stat-ism has been wish us, and distinguishes us from other countries like Canada that are used to stronger forms of executive government going way, way back.  I think what Americans particularly dislike and fear is any kind of bureaucracy or back in Ed and Peter’s day, functionaries, kind of that administration officials telling them what to do.  Now, why they don’t think insurance company functionaries are bureaucrats who are controlling their medical care, it’s a mystery to me, except in a historian I know that Americans have always distinguished between the two.  Americans spend a ton of money, public money, on health care, but they do it by giving private employers tax breaks.  And in fact, by giving employees tax breaks for the benefits that we get.  We spend hundreds of billions of dollars each year on that, almost as much as Medicare, but there’s no visible government bureaucrat sitting there.

Caller Kathy: I think it’s a really interesting point that you’ve just made, and it’s interesting that people seem so strongly resistant to having someone tell them what to do when profit is not the main motive, but they don’t seem to mind it as much when profit is the motive.  Maybe that’s because it let’s us still feel as though the free market is keeping us free.

Ed:  Yes, I think that’s right.  We’re assuming that the invisible hand is somehow making sure that, I know it seems very expensive to have $80,000 for this toenail removal, but it must be the market, so it must be OK.  Though to go back to your original question, is there something special about health care, and I think there is, and I think there’s two currents that are joining, that are making the current debate so livid:  one, anything that deals with the body, and you raise the issue of intimacy, is very powerful, and Peter had mentioned fluoridation, and it’s hard for us to imagine what a prolonged and fervent debate that was in the 1950s, about the infiltration of our bodies by this chemical that’s being put in the water, and the Communist one is to do that; but also, of course, is the abortion debate.  And you think about what the bumper stickers and things that are about, such as “keep you laws off my body” and both sides of these kinds of things, and health care itself is the entire range of everything touching your body.  So I think there’s something especially alarming to some people about the idea of the government touching your body.  And now, why the government?  Well, my dad used to have a saying when we were out planting a tree or doing some work around the yard, he’s say, “Well, we’re done.  That’s good enough for government work.”  And that would be just a joke, that is was OK, we did it halfway, the way that the government would do it.  We imagine the invocation, and I say this with full respect for anybody involved in motor vehicle registration, DMV and health care is the image that Americans have at all this.  So it’s the inefficiency they imagine of the government, combined with the invasiveness of touching your body that I think just drives people crazy about this.

Peter:  Kathy, thanks for calling.

Brian:  I hope we were good enough for government, Kathy.

Caller Kathy: Thanks.   Bye.

Ed:  It’s time for another short break.  When we get back, we’ll take more of your calls about the history of health care in America.


Peter:  Remember, if you’d like to join us on a future show, have a look at our website to see the topics we’re working on.  We’re at

Ed:  Underwriting support for BackStory comes from the Colonial Williamsburg Foundation, committed to the idea that the future may learn from the past.

Peter:  This is BackStory, the show that looks at the past to explain the America of today.  I’m Peter Onuf, your 18th century history guy.

Ed:  I’m Ed Ayers, 19th century guy.

Brian:  And I’m Brian Balogh, 20th century history guy.  Today, on the show, the history of health care in America.

Peter:  We’re going to take another call now.  It’s from Brenda out in DesMoine, Iowa.  Brenda, welcome to BackStory.

Caller Brenda:  Thank you very much for having me.

Peter:  Well, we’re talking about health care, which is on everybody’s minds now and I’m sure on yours, too, that’s why you called.

Caller Brenda: Yes, it is.  I wanted to get your opinion on what you might call “rising expectations”.  Like I said in one of my entrants on your website, I’m an asthmatic, but it’s not like you can tell by looking at me.  I know that medical technology and research has gotten to the point where there are drugs to treat it now.  That was not always the case.  So I wanted to hear from you about how we expect more, it’s like our  standards have gotten better.

Brian:  That’s a great questions, and I’m curious, Ed, when did actual expectations for health begin to rise.

Ed:  I was going to say that it’s much more in your period than in mind.  Because, in the 19th century, there were really no medical breakthroughs all the way through the era of the Civil War.  It was not until pasteurization and this kind of more public health discoveries in the later 19th century that you started seeing things, and they didn’t even know that mosquito caused illness, they thought it was my asthma, lifting out of the swamps, so my sense is that it was not really until the early 20th century that you would have seen very great breakthroughs in health expectations.

Brian:  I would agree that, though I’d back up a little bit and go back to your point about public health, because public health improving it in the late 19th century, right on the edge of your period and mine, it entailed massive investments in water, in sewar systems, in cleaning up cities, and I have to believe that people weren’t willing to spend that kind of money, those kinds of tax dollars, if they didn’t have great expectations for improving health.  Would you agree?

Ed:  I would say by the last decade of the 19th century, but you’re still having, as late at the 1870s, horrific outbreaks of yellow fever and other diseases that we’ve now mastered, that were complete mysteries to people.  They could the same thing as back in the 18th century of quarantines.  So, you’re right, Brian, they began to clean things up, but it still wasn’t part of a comprehensive understanding of where disease came from.

Caller Brenda: Yeah, if you say that some of it is that we didn’t know about disease or understand it, this happened, life was nasty, brief and short and that’s just the way it was.  Then we started to get better technology and understanding how to do things, and then pretty soon it becomes almost what the Catholics might call a “sin of omission”.  Now that we can do surgery, it’s terrible to let some child with a cleft pallet just go.  If a woman has breast cancer, it’s almost expected to be able to do reconstructive surgery after the mastectomy, and that kind of thing.  The child with the cleft palette is going to have trouble with swallowing and speaking, but the child isn’t going to necessarily starve.  It’s almost like if you have the ability to help somebody, then isn’t it almost wrong not to.

Peter:  Brenda, what I think I hear you saying is that there is an idea of the normal.  The normal is the normative, that is, we have both a focus on the individual, yet we measure ourselves against some kind of universal yard stick, and that is where you get to your rising expectations, because if we keep taking up the yard stick, because we keep saying this is the way we all ought to be, and all public health now is essentially a bully pulpit in which people tell us we should be thinner, we should be eating better, we should be aspiring to a better, healthier life.

Ed:  And even more than that, Peter, this is the century in which plastic surgery is really soaring, and we have not only the expectation of health, but of beauty.  They couldn’t even perform the most basic surgeries without killing people back in the 19th century, and now with all the anesthetics and anesthesia and everything, it seems a routine thing to be slicing people’s faces and all that.

Peter:  Which is why we’re on radio.

Ed:  But, anyway, this is where I think Brenda’s question is actually profound.  I think it’s not merely the expectation of health, but the expectation of everything, and one reason the current health debate is so heated is that the stakes seem so high now, because what we expect from health care seems virtually unlimited.

Peter:  Thanks for calling.

Caller Brenda: Thank you.

Peter:  Hey, guys, we got another call.  It’s from Brent in Cleveland, Ohio.  Brent, welcome to BackStory.  What’s on your mind.

Caller Brent:  As a native Clevelander and someone’s who has lived all over the country and sort of the urban north and the rural south, I’m really interested in how people in those areas of those country are likely to react to the health care debate today; and I wonder if the way they reacted is colored by political and cultural history that are tied to the regions.  I’ll get more specific, I know that in the wake of the Civil War, the Federal government gave penchant to the Union soldiers and their families, but not to Confederate soldiers and their families, and so what I’m wondering, is whether that legacy has shaped the way people in the rural south and in the north view the Federal government and its efforts in health care, and whether there have been disparities at other points along the way health care and penchants and all that in the way they’re shaped by north/south or urban/rural disparities.

Peter:  Brent, you want to know if regional differences explain some of the brouhaha over health care, and whether we can give some historical perspective on this.  What do you think, Ed, you’re a southern boy.

Ed:  I am and that was many interesting questions put together.  You’re exactly right that there was a lot of resentment for a long time that a lot of men with missing limbs and disfigured faces really had no support from the Federal government at the very time in time in the 1890s, in particular, when people were growing old, and the state governments in the south ended up spending a large part of the budgets on artificial limbs and care for the Confederate soldiers.  Here in Richmond, there’s a Confederate Soldier’s Home that private money would go in to do all these things.  So you’re exactly right in that analysis.  And another way you’re exactly right is the enormous health disparity between the north and the south today.  If you look at maps of social well-being and various instances of maladies, the south is so much worse off then the rest of the country, and part of it, is the black belt, as part of the African-American population and there’s neglect there.  Another part of it is Appalachia, where you have really great shortages there.  But here’s the paradox, Brent, the people who are  most opposed to the health care plan do tend to live in the south, and do tend to be people of economic need, but you find that those are the states, ironically, that actually get more from the Federal government; whereas, in the liberal states, which are actually net payers to the Federal government, are in support of health care.

Caller Brent: So what I’m wondering about is whether the lack of Federal expenditures  has maybe even caused some of the more recent Federal expenditures; maybe if Federal government had actually helped out with some of the needy in the 1890s, that maybe the states would not have had to spend so much, and they might have been able to put some dollars into development.

Ed:  Well, I think the Federal government wanted to give money for them, and the southern states actually resisted, and would help the black population, and for well-known reasons, the southern states did not want to open the door to Federal involvement in their affairs because they were flouting the 15th Amendment.  I don’t think it’s the lack of earlier investment, except maybe in the New Deal.  The iron is, we have irony and paradox, is a bonus, of southern history, is that southerners, black and white, pride themselves on not needing doctors as much.  And it’s a part of the cultural tradition that you basically have to be in really bad shape before you’ll go to a doctor and that does, to me, look like a cultural thing.  It looks like an aversion to expertise, or meddling, or that sort of thing.

Peter:  Except if you’re from South Florida.


Peter:  That’s the highest per capita use of medical services in the entire country is in South Florida.  Three times per capita than what it is in Buffalo, New York and Miami.

Ed:  Well, that’s so far south, it’s north.

Peter:  No, it’s not really part of the south.  But I don’t know, Brian, would do you think about this.  Can we trace that tradition back, this kind of willingness to look to government for solutions?  Is that part of the civic culture of the north as opposed to the south?

Brian:  Well, I think that it is.  But, the 20th century, as it tends to do, guys, tends to complicates things a lot.  Brent started out by asking about the implications of war and the military on social and health provisions.  When you run that forward into the 20th century, what you get is what Ed was eluding to, that is increasing expenditures that are going to the south, and that’s in the form of military bases, but that’s also in the form of Americans serving their county.  After WWII, the only Americans, the only large group of Americans that received regular, and pretty good, medical care from the Federal government were veterans.  They received it through these veterans facilities, but this is where the ironies and the paradoxes of the south come into play, because those facilities also discriminated against African-Americans, and African-American veterans.  So even though they were entitled to these medical services, they found it a lot harder to receive them.  But this is when I think the south started benefiting from Federal largess in health care, perhaps, in a disproportionate way.

Peter:  Brian, don’t you think it’s also true that Americans have a genius for feeding at the Federal troth and then denying that they’re dependent on it.

Brian:  Oh, no question about it.

Ed:  I heard a guy the other day say, “I don’t know why these people have to have the government, because back when I was poor, I was on Welfare and Food Stamps, and I never asked the government for anything.”  [laughter]  So what do you think, Brent, did we get anywhere close to answering your question in a persuasive way?

Caller Brent: You sure have revealed the paradox that I was trying to get to.  How was that?

Ed:  That’s a very polite and ironic answer to our question.

Peter:  It’s a sign of being a sophisticated historian.  Welcome to the club, Brent.  Good to talk with you.


Ed:  So, it seems to me, Brian, that in the current debate, people who are trying to sell the nation on this public health care system, keep talking about efficiency and cost and all those kinds of things.  Rather than much of a morally charged responsibility.  It shifts over to a cost accounting model, rather than a more communitarian model.

Brian:  That’s such a good and important point, Ed.

Ed:  When Truman proposed health care, and when Roosevelt was building up to it in the 30s, they both talked in terms of obligations, the reciprocity of citizenship.  And it was a time when Americans were asked to make huge sacrifices for their country.  And I don’t mean to demean the sacrifices that our fighting men and women are making today in Iraq and Afghanistan, but they are a sliver of the American population.  Truman was addressing a population that had just sacrificed collectively, and that’s how there was broad support for providing good medical care to millions and millions of returning veterans, because they had sacrificed the relationship between the obligations to government and the benefits that one could expect back from government were crystal clear in those days, or at least as clear as they get in a democratic republic.  So let’s imagine what it looks like to the many Americans who oppose anything like this and the energy that they bring to it.  You could argue that because of the history that Brian’s told us about how insurance became linked to employment, it’s not unlike the health care given to returning G.I.’s.  It’s that they had earned it; I have earned this, it’s a part of my benefit fix that I get, and that what you want to do is give away something for nothing.  Even Social Security, right, is a return for services rendered.  So, I think that what we have here is the lack of a mechanism to explain how somebody deserves health care merely for being a part of the community, merely for being an American.

Peter:  So, Ed, you would say at the end of the day that we end up with ideological and even rhetorical problems about how we describe and mis-describe the world we live in.

Ed:  Yeah, because we don’t really have a language, really just as unabashed communitarian, not Communism, not Socialism, just collective responsibility.

Peter:  Well, we have Nationalism, that may be the closest we get, and that’s why war time is so crucial.

Brian:  Yes, but you know guys, we did have that language back in your century, because everybody understood that somebody who had a communicable disease, whether they had a job or not, whether they were a brave soldier or not, could get everybody else sick, and so the steps that needed to be taken were collective.  The language was collective, so we have progressed to the point where we feel safe from other people’s misfortunes, and the illnesses all seem internal.  The ones that we can’t lick – heart disease, cancer, all those things seem like something that well up from within and may be even our fault.  We didn’t eat right; we didn’t exercise; smoking.

Ed:  Look at the way it is today with Swine Flu.  Nobody’s blaming anybody else for getting Swine Flue; they’re just saying it’s an epidemic.  So it’s by the changing nature of the diseases that are killing us, as well as the changing nature of the technology that these diseases are fixed.

Brian:  Because we’ve done so well, in general, at dealing with those communicable diseases, so we’re left with those individual diseases, and that really plays into American’s pre-existing condition, if you will, of seeing things through individualistic terms.

Peter:  Well, Brian, everything you’ve said makes a lot of sense except that it is that the sense of the individual and of the individual’s health, body, this individualistic focus has developed in the 20th century.  It’s not that we can think back into the 18th century and think about Adam Smith and the market and we can blame all of these enlightenment thinkers for this modern solipsism and narcissism and obsession with self, but the idea that Smith and other moral philosophers of the enlightenment had is of human nature to be naturally sociable; that is, that we’re drawn to others, to do well for others, to take care of others, with the family being the model or the paradyn for the society as a whole.  The point market transactions is not the aggrandizement, that’s a by-product of it.  It’s to promote the health of the nation, you might say.

Ed:  You know, Peter, even if I disagreed with you, I couldn’t argue with you because we’ve run out of time again.  But remember, our conversation is always going on at our website.  Please pay us a visit and tell us whether the history of health care in America makes you optimistic or pessimistic about the path ahead of us.

Peter:  Again, that’s  Don’t be a stranger.

Brian:  BackStory is produced by Tony Field, Rachel Quimby, and Catherine Moore, with help from Lydia Wilson and Bart Elmore.

Peter:  Jamal Milner mastered the show and Gabby Alter wrote our theme.  BackStory’s executive producer is Andrew Wyndham.

Ed:  Major production support for BackStory with American Backstory hosts is provided by the David A. Harrison Fund for the President’s Initiatives at the University of Virginia, the National Endowment for the Humanities, the University of Richmond, Carrie Brown Epstein and the W.L. Lyon Brown, Jr. Foundation, UVA’s Miller Center of Public Affairs, and an anonymous donor.

Peter:  Support also comes from James Madison’s Montpelier, Marcus and Carol Weinstein, Trish and David Crowe, and J.M. Weinberg.

Peter Onuf is the Thomas Jefferson Memorial Foundation Professor of History at the University of Virginia.

Brian Balogh is an Associate Professor of History at the University of Virginia and UVA’s Miller Center of Public Affairs.

Ed Ayers is the President and Professor of History at the University of Richmond.

BackStory was created by Andrew Wyndham for VFH Radio at the Foundation for the Humanities.

View Resources

Further Reading

All Centuries
  • Primary sources on women in the medical field, including letters, diaries, photos, and oral histories
  • Dozens of historians weigh in on the health care debate
18th Century
19th Century
20th Century & Beyond
American Presidents on health care:


  • Photos of the recreated 17th century hospital at Mt. Malado: 1, 2, 3
  • The Memory Palace,” Nate DiMeo’s podcast about American history