The Challenge of Universal Health Care:
Social Movements, Presidential Leadership,
and Private Power
Does health care transformation happen from the top down or from the bottom up? In the case of universal health coverage, two of the major obstacles preventing the establishment of national health insurance in the United States have been a lack of leadership from above, and a lack of popular mobilization from below. As Constance Nathanson argues in this volume, social movements require powerful allies within the state if they are to achieve success. On the other hand, powerful leaders, even presidents, who act without the support of a popular movement have not been able to make headway against the entrenched private interests opposing health system transformation.
This chapter looks at the relationship between health care reform from above (elite reformers and the White House) and from below (social movements) throughout the twentieth century to demonstrate that only when the two came together was systemic change ever achieved. I also argue that the convergence of presidential leadership and social movement mobilization is even more crucial today because of the need for a counterbalance to the massive private health insurance industry. The public/private nature of the U.S. health care system, and especially the presence of a multibillion-dollar insurance industry, makes transforming that system extremely challenging for both political leaders and for social movements.
It is no coincidence that the historic attempts to establish universal health care in the U.S. are associated with presidents (Harry Truman, Lyndon B. Johnson, Bill Clinton)