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Care or Control? How the Government Regulates Health

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Amid the chaotic controversy over the 2009 Health Care Bill before Congress, cries of “socialism!” abound. Conservatives and libertarians fear the government has overstepped its bounds in seeking to control health care options for private individuals. They talk of “pulling the plug on Grandma,” concerned that end-of-life decisions will no longer be for doctors, patients, and families, but will be a matter of public policy. And they decry a public option, fearing that it would limit the availability of doctors and treatments. 


Whether or not you agree with these positions, the truth is that the U.S. government has always been closely involved in our health care. We may not have socialized medicine, like France and Canada do, but public health initiatives were in place long before the 2009 Health Care Bill. 


Lighting Up Is a Public Affair
Cigarette taxes have been in place in America since the early settlers. In the beginning, taxes were usually imposed because tobacco was so profitable that the government relied on this cash crop to meet its shortfalls. For example, the first federal (not state-controlled) excise tax on tobacco was levied to fund the Civil War. Once research emerged, in the 1940s, on the ill effects of smoking, the government gradually changed its justification for taxing cigarettes. By the 1960s, the legislative focus had shifted toward curbing this public health concern through a variety of measures, in addition to increasing taxation. 


In 1965, Congress passed the Cigarette Labeling and Advertising Act, which required all cigarette packages to bear the label “Cigarettes may be hazardous to your health.” Five years later, the Public Health Cigarette Smoking Act banned advertisements of cigarettes on television and radio. Since 1998, it has been illegal to sell cigarettes and other tobacco products to people under age eighteen, though some states have raised the age to nineteen. Today, state- and municipality-mandated smoking bans in restaurants and outdoor spaces are perhaps the most invasive public measure to curb smoking. But all of these governmental restrictions have achieved their common goal of ending smoking, to a large extent: since 1965, the number of Americans who light up has dropped by half. 


Eyes on Your Plate
What could be more personal than the food you put in your body? And yet government legislation has concerned itself with nutrition since the late nineteenth century. The U.S. Department of Agriculture (USDA) published the first national dietary guidelines in 1894, even before the discovery of vitamins and minerals in the early twentieth century. In 1941, under the direction of president Franklin D. Roosevelt, the USDA developed Recommended Dietary Allowances (RDAs) at a National Nutrition Conference. The RDAs specified caloric allowances for Americans, as well as requirements for essential nutrients. 


The USDA has also controlled how we group foods. In 1943, it announced the Basic Seven, but then quickly simplified things to the Basic Four. For the next twenty years, Americans thought of food as milk, meats, fruits and vegetables, or grains. Then, out of concern for a rise in chronic diseases like heart disease and stroke, the USDA decided to regulate what it considered unhealthy foods by adding a fifth category, fats and sweets, for moderate consumption. Finally, in 1992, the department released the Food Guide Pyramid that we know today, which organized these groups into an easy-to-use graphic format. By picturing a range of foods and visually sizing food groups, the illustrations and text convey the USDA’s three main objectives for the American diet: variety, proportionality, and moderation. 


Though these food guidelines are part of schools’ required curricula, they remain recommendations and not laws. But the tide is shifting as Americans grow more concerned about rising rates of obesity and related diseases, like diabetes. New York City requires fast-food restaurants to post the calorie counts of all foods. New York State banned trans fats from restaurant menus, and governor David A. Paterson has proposed an “obesity tax” of about 15 percent on all non-diet soft drinks. If these initiatives are successful, it’s possible that they may be implemented on a national scale. 


Politics at the Doctor’s Office
Congress is still hammering out the exact terms of the 2009 Health Care Bill, but the plan president Barack Obama proposes calls for a single-payer universal health care system in which a government agency, rather than individual employers, would collect medical fees and pay for services. Though Republicans in Congress are resisting that idea heavily, there still remains the possibility of a public option, a government-run health insurance program that would compete with private plans to drive down costs. Again, this, too, is meeting with much resistance, and there is so much controversy over the bill that we won’t really know what the final product will look like until Obama signs it into law. 


The 2009 bill is not the first time that nationalized health insurance has emerged to heated debate. President Harry S. Truman requested that Congress establish health insurance plans for all Americans in 1945, but quickly backed down after opponents warned vociferously of the dangers of “socialized medicine.” In 1965, as part of his Great Society domestic policy, president Lyndon B. Johnson legalized Medicare, which provides health care coverage for Americans aged sixty-five and over, and its companion program, Medicaid, which insures low-income individuals and families. Throughout the latter part of the twentieth century, these two programs were subject to several governmental reforms aimed at reducing costs and expanding coverage. 


And, of course, there was the health care debacle of 1993, spearheaded by then–first lady Hillary Clinton. The Health Security Bill was a complex proposal of more than one thousand pages that required all employers to provide health insurance coverage to all of their employees through competitive but closely regulated health maintenance organizations (HMOs). Conservative, libertarian, and health care industry opponents criticized the bill as being too bureaucratic and restricting patients’ choices, and the hue and cry made health care a taboo issue until aging baby boomers threatening to overtax Medicare brought us to the 2009 bill out of necessity. 


A National Health Crisis
Are we headed toward socialized medicine? If we are, that trend started long before President Obama proposed a public option. The U.S. government has a long history of legislating—some would say obtruding—on citizens’ health. This is nothing new, and if there were ever a time when we need the government to interfere, it is now. Approximately fifty million Americans are without health insurance, and more than one million workers lost health care coverage in the first three months of 2009 alone. Health care costs are skyrocketing, making a broken leg or illness a catastrophic event for someone without insurance. Who knows if the 2009 Health Care Bill will provide a solution? What we do know is that there is a huge problem.

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