With the Patient Protection and Affordable Care Act (ACA or, if you prefer, ObamaCare) again threatened with repeal—including its provisions for requiring coverage for people with pre-existing conditions and 10 essential benefits, which in turn include treatment for substance use disorder—it’s a good time to reflect on the past and future of universal health care coverage in the US.

Many presidents have proposed something like “universal health care”, but have failed due to politics, fear-mongering, and the opposition of the American Medical Association. (That the ACA passed may have been in part because the AMA supported it. Previous repeals may have failed in part because the AMA opposes repeal without replacement.)

For example, in his failed 1912 bid for a third term as president, Theodore Roosevelt’s Progressive Party Platform proposed a “national health service” to guard “against the hazards of sickness, irregular employment and old age through the adoption of a system of social insurance”.

Similar attempts failed in 1915 and 1920 when opponents compared them to programs in Germany (then our adversary in the first World War) or denounced them as socialized medicine”.

Another Roosevelt, President Franklin Delano, indirectly led to employers offering health insurance as an employee benefit when World War II wage and price controls didn’t allow them to use higher salaries to lure scarce workers.

Attempts to extend health insurance to various degrees failed under Harry S. Truman (“socialized medicine” again), Dwight D. Eisenhower, and John F. Kennedy. Lyndon B. Johnson did manage to enact Medicare and Medicaid, and Richard M. Nixon created HMOs with the Health Maintenance Organization Act.

Jimmy Carter’s attempt never got to a floor vote, Ronald Reagan’s Medicare Catastrophic Coverage Act was mostly repealed by Congress during George H.W. Bush’s tenure, and Bill Clinton’s American Health Security Act died under a well-organized and well-funded negative campaign. (Clinton did enact the Health Insurance Portability and Accountability Act or HIPA.)

George W. Bush didn’t attempt a major overhaul but did increase prescription drug benefits with the Medicare Drug Improvement and Modernization Act, against Congressional opposition. And of course, Barack Obama passed the ACA.

Now, it is up to the courts again, which are asked to consider whether or not the ACA is constitutional. Although such a finding would eliminate protection for people with pre-existing conditions and guaranteed coverage for substance use disorder, mental illness, or both (dual diagnosis) supporters say they would restore those rights with separate legislation.

The call for improved health care is based on three main factors: access, cost, and that we are one of the few wealthy industrialized nations that do not offer guaranteed health care coverage to its citizens.

With costs still rising, drug overdose deaths increasing, and average life expectancy dropping, something needs to be done. Making treatment for substance use disorder more difficult to obtain seems to be going in the wrong direction.

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