ACA repeal recalls politics of maternity and infant care ... in the 1920s

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Poster for Children's Year, April 1918-April 1919, which soon led to a highly politicized, Obamacare-type controversy. Lithograph by Francis Luis Mora. (Library of Congress)

It was no surprise that Republican members of the new Congress, sworn in just 10 days before, voted last week to repeal the Affordable Care Act, and they have vowed to slash or transform other health programs including Medicare and Medicaid. Obamacare may be new but much of the politics is not. Perhaps you have heard of the Maternity Act of 1921?

In 1920, the United States Children’s Bureau released a report detailing the success of its Children’s Year program, a homefront effort during World War I. The agency proposed to build on its wartime work by providing federal funds to the states for maternity and infant care. Soon, Republican Representative Horace Mann Towner of Iowa and Democratic Senator Morris Sheppard of Texas, introduced supportive legislation officially titled the Promotion of the Welfare of and Hygiene of Maternity and Infancy Act but often known simply as the Maternity Act or Sheppard-Towner. The measure aroused the anger and political might of organized medicine, led by the American Medical Association and joined by political conservatives. Opponents charged that federal funds for maternal and infant services would overstep the divide between federal and state responsibility for public health and between elected officials and private citizens. Physicians, under the umbrella of the AMA, claimed the legislation would undermine the fee-for-service model of private medical care, which remains dominant today. Only groups representing pediatricians and women physicians supported the measure.

After a fierce battle, Sheppard-Towner passed in 1921. It would be a short-lived victory—made possible by the 19th Amendment, as many elected officials feared antagonizing newly enfranchised women voters and voted for the law. It enabled the Children’s Bureau to distribute funds to states to reduce maternal and infant mortality through public health programs that included maternal education, nurse visits, midwife training, and health exams. Only three states—Connecticut, Illinois, and Massachusetts—rejected the federal funds offered to them. Most put the money to good use. Ohio used the funds to support demonstration projects, including one designed to meet the needs of the African American mothers and babies in Cincinnati, as well as health clinics, educational programs, and pre and post-natal home visits by nurses. Sheppard-Towner dollars did not pay for medical services; clinic nurses referred infants and children found to need care to community doctors for treatment. The fee-for-service model of health care survived.

As measured by returns in public health, Sheppard-Towner proved enormously successful. Thanks to the funds, the nation experienced a decline in the infant mortality rate of between 9 and 21 percent during the seven and a half years the law remained in effect. Funding ceased in 1929, due in large part to the efforts of the AMA and as elected officials learned that women did not vote as a bloc. Powerful political forces killed an effective public health program serving the nation's children.

In 1930, one year after the demise of Sheppard-Towner, the secretary of the interior, a physician named Ray Lyman Wilbur, addressed the White House Conference on Child Health and Protection. Dr. Wilbur acknowledged both the federal government's interest in the young—“Every child is now our child”—and the limits of federal action: “No one should get the idea that Uncle Sam is going to rock the baby to sleep.” Maybe politicians and physicians didn't want Uncle Sam himself in the nursery, or maybe the public really didn't want him there, but Americans didn't seem to mind getting a helping hand by way of federal investments in health care. In 1937, 10 years after funding ended, the Gallup Organization took a poll and asked: “Should the federal government aid state and local governments in providing medical care for babies at birth?” The pollsters heard a resounding yes: 74 percent to 16 percent (the remainder had no opinion).

Fast forward to today. President Obama’s Affordable Care Act led to a drop in the uninsured rate of more than 6 percentage points to a historic low, and subsequent improvements in health status. Because there is powerful evidence for the value these programs deliver in terms of life saving health care, the opponents are left to make rhetorical attacks. While some complaints focus on costs, difficulty accessing providers, and inefficiencies, others focus on philosophical matters, charging that Obamacare represents federal government overreach, socialism, an abridgement of states' rights, and interferes with private family matters.

Meanwhile, a new poll released Tuesday showed the ACA with the highest level of support since it passed, although the public remains deeply divided. The nonpartisan Congressional Budget Office projected that at least 18 million people would lose their health insurance if Republicans decide to repeal the law in ways similar to what they have attempted in the past, but President Obama vetoed. President-elect Donald Trump has said that his own proposal, expected soon, would have a goal of “insurance for everybody” but has released few details.

As we watch the new Congress attack existing health-care programs we should listen carefully for echoes of past attacks. We will certainly hear salutes to the needs of all the citizens or perhaps to children, and we will also hear pithy phrases about why the federal government should step back from funding health care. What we need to be hearing instead are the voices of citizens who benefit from health insurance programs and the accounts of experts who can demonstrate why the dollars spent on health services save lives and make a healthy society. Let's not go back to 1930.


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