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BY: CLAY O'DELL, PhD

Much has changed since this journal began publishing in 1919. At that time, the then-Catholic Hospital Association was only 5 years old. Based in Milwaukee, Wis., at the time, it was founded as an outlet for the nation's approximately 600 Catholic hospitals to share operational best practices and ideas to help maintain their mission and identity. "Advocacy," or government affairs, was not one of CHA's core activities when Hospital Progress debuted in 1919. This was hardly surprising given the federal government's small role in the health care industry at that time. But over the course of the next century, the government's role and the role of health care organizations such as CHA would change dramatically, making advocacy one of CHA's top priorities. As we celebrate the birthday of Health Progress, we reviewed some highlights of the Catholic health ministry's advocacy initiatives over the last century, as seen through the lens of Health Progress and other sources.

BEGINNINGS
As CHA and Hospital Progress debuted, the Catholic Church and its institutions held a very different place in American political society than now. Outside of major urban areas like New York City, the Catholic presence in the political leadership and culture of the United States still lagged far behind that of mainline Protestants. Rome remained extremely wary of the American political system, and many American non-Catholics still considered the Catholic church to be an anti-democratic relic of the Old World. One of the first major inroads of the American Catholic church into U.S. political discourse came into being the same year as Hospital Progress, when the National Catholic Welfare Council (later known as the National Catholic Welfare Conference or NCWC, the precursor to today's United States Conference of Catholic Bishops) was established in Washington, D.C. Under its first chair, San Francisco Archbishop Edward Hanna, the NCWC became the official Catholic organization to engage in U.S. domestic policy. But as the 1920s progressed, the Catholic Church in many ways remained at the periphery of the political establishment.

During those years, the government's involvement in the health care industry remained minimal, and the notion of what we might call "health reform" was still very much in the future. But Americans did begin to see access to health care in a different light in the 1930s as the Great Depression deepened and many Americans lost their jobs, their income and their ability to pay for care. In 1935, President Franklin D. Roosevelt signed the Social Security Act, one of the largest expansions of social insurance in our nation's history. Initially, the bill included a provision calling for the federal government to study the feasibility of a national health program, but just the mention of it prompted a deluge of telegrams to members of Congress "from all parts of the country protesting against this 'nefarious plot.'"¹

The next major milestone in health reform came after World War II, when President Harry S. Truman's administration became the first to make a major legislative push for a universal health care program. The plan was met with fierce opposition by the American Medical Association, which labeled it "socialized medicine" at a time of growing American fear of Communism.² Truman was forced to withdraw his plan, and the momentum for any type of national health insurance was lost for a generation. About the same time, the way Americans accessed health care also was undergoing a major shift. During the war, wage and price controls forced many large companies to offer supplemental benefits, including health coverage, in order to attract employees. The growth of health insurance companies such as Blue Cross helped fuel the trend, and even after the war ended more and more Americans began to have their access to health care tied to their employment. Although the advancement of employer-based health insurance through the 1940s and '50s improved access to care for many in the middle class, it still left vulnerable segments of the population — the unemployed and the elderly in particular — at the mercy of out-of-pocket medical costs.

THE GREAT SOCIETY
In 1964 President Lyndon B. Johnson was elected with over 60 percent of the popular vote and carrying 44 of the 50 states. Johnson's Democratic Party also swept to victory in Congressional elections that year, putting in place a solid majority in the House of Representatives and a filibuster-proof majority of 68 in the Senate. President Johnson had campaigned on improving the lives of Americans through a series of programs he termed the "Great Society," and in his State of the Union address on January 4, 1965, he called on Congress to provide hospital care for seniors under an expansion of the Social Security Act.³ Following the address, the "National News" column of Hospital Progress made note of the President's focus on health care and advised that "official Washington is convinced that the medicare [sic] program will be enacted before the end of the year."⁴ Congressional Democrats immediately introduced legislation to enact a national health program for seniors 65 and over, establishing the federal government as the payor for hospitalization services and establishing a voluntary supplemental insurance program for other health services. Ways and Means Chairman Wilbur Mills (D-Ark.) shepherded a bill through his Committee largely based on the Administration's plan, the Social Security Amendments Act of 1965, which passed the House in March. Liberal Democrats in the Senate attempted to expand the program's benefits by amendment, but Chairman Mills stripped out most of these in his conference report. The final legislation passed the House and Senate in July and was promptly signed into law by President Johnson. In addition to the new Medicare program, the bill offered matching federal funds to states to provide health care to those who qualified for public assistance programs, which eventually became the Medicaid program.

As Congress debated the Social Security Amendments bill, the Catholic Hospital Association joined with other health provider associations to contact lawmakers with their concerns. At that time, CHA's sole office was in St. Louis, and it did not have a distinct government relations department. CHA instead relied heavily on both the American Hospital Association and the NCWC for its advocacy information and positions, as articles in Hospital Progress from that era suggest. Given CHA's later strong support for the programs that came out of the 1965 legislation, one might assume that CHA would have championed the bills in Congress. But CHA expressed objections to the legislation's treatment of payment for specialty services in hospital settings.⁵ Other provider organizations, most famously the American Medical Association, remained quite wary of the attempt to form any sort of national health program. Having objected to similar proposals before, and with the momentum in Congress growing to pass the new Medicare legislation, they doubled their efforts. The American Medical Association once again led with the most vocal opposition to the administration's plan, launching a public awareness campaign against Medicare in January of 1965 and featuring such efforts as full-page advertisements in 100 newspapers nationwide denouncing the proposed program as "the beginning of socialized medicine."⁶ While the campaign garnered much public and media attention, it seems to have been less effective in swaying public opinion. In March of 1965, a nationwide survey registered strong support of 62% for the President's Medicare proposal.⁷

CREATION OF CHA GOVERNMENT AFFAIRS OFFICE
Regardless of CHA's stance on the creation of Medicare and Medicaid, the advent of these new programs would dramatically alter both the provision and reimbursement of care for hospitals as well as their relationship to the federal government. The government now had the ability to use the Medicare program to effect changes in health care settings by utilizing conditions of participation. One very dramatic example occurred in 1966, the first year of Medicare's implementation, when as a condition of participation all hospitals were required to comply with the Civil Rights Act. Within the very short period of four months in that year, over 1,000 hospitals integrated their medical staff, waiting areas and patient floors for the first time.⁸ Medicaid also continued to grow and become an increasingly important program in the provision of health care in the U.S. One year after the law was passed 26 states had adopted the option to participate in the Medicaid program. Just four years later, the number had grown to 48.⁹ The enormous influence these new programs had over hospitals meant that the organizations representing them had to take on new responsibilities in the area of advocacy. For CHA and the Catholic Church in the U.S., this decade also witnessed the tremendous changes brought about by the Second Vatican Council as well as the first Catholic president. The church and its institutions, including hospitals, had entered a new era of participation in U.S. political advocacy and public policy.

The next major milestone drawing CHA further into federal advocacy came in 1973 with the Supreme Court decision striking state bans on abortion. With the Catholic Church strenuously opposed to abortion, its nationwide legalization posed a threat to Catholic hospitals. Two issues in particular arose following the court decision: whether federal funds would now be provided for abortion services, and whether Catholic hospitals would be allowed to refuse to provide those services without facing punitive measures. CHA responded to the new landscape by creating two new departments, one for Government and Legislative Services and one for Legal Services. The creation of its own legal and legislative departments put CHA in a position to engage more fully in the affairs of Congress and the administration. One of the first major duties for the new departments was the preparation of model "conscience clauses" to protect Catholic institutions and employees from having to provide abortion services.¹⁰ In September of 1976 CHA's government affairs and legal departments were moved to a new office located in Washington, D.C. Over the next several years, CHA became fully engaged in providing government affairs information, legislative analysis and regulatory updates for the Catholic health ministry.

CLINTON HEALTH PLAN
By 1992, the number of Americans without health insurance reached a historic high of 15 percent of the population. While Medicare, Medicaid and employer-based private insurance largely met the health needs of millions of Americans, the recent recession and rise in unemployment made health security a top issue in that year's presidential campaign. Another source of concern that year was the rising cost of health care, with spending growing exponentially over the previous decade. The Democratic candidate, Gov. Bill Clinton of Arkansas, made health reform a prominent feature of his campaign. Then, in the fall of 1992, Clinton proposed overhauling the current system to impose an employer mandate for health coverage; create a national health care board to lower health costs and government spending; and combine Medicaid with newly created state purchasing pools to cover small businesses and individuals.¹¹ In response, the incumbent, President George H. W. Bush, proposed a program offering tax credits to individuals to purchase private coverage. Like Lyndon Johnson before him, Clinton was elected with substantial majorities in both chambers of Congress, giving new momentum for the first major health reform initiative since the 1960s. This time, CHA and its Washington-based Division of Government Services was well placed to play a greater role in the debate around health reform. In the January-February 1993 Health Progress, CHA outlined an action plan for the Catholic health ministry that focused on three goals: forming partnerships with other organizations advancing health reform; encouraging the ministry to meet frequently with their members of Congress to discuss emerging proposals; and creating a legislative action plan to respond to the Clinton proposal.¹²

Building on the association's proposal for health reform from 1991, CHA stressed four advocacy positions that must be included in a reform plan. The four were universal coverage, a uniform comprehensive benefit package acceptable to most people, delivery reform via clinically and financially integrated networks, and reliable and fair expenditure control.¹³ In November of 1993 President Clinton's plan, the Health Security Act, was introduced in Congress. As the bill was debated over the next year, CHA and its members engaged in a spirited campaign to achieve health reform. Health Progress instituted a special section called "Reform Update," and in March of 1994 also announced an additional biweekly newsletter called Washington Reform Update to help keep the ministry informed about the legislation (this would continue later as CHA's Washington Update, still published today). Throughout that busy year, most of the articles in Health Progress stressed CHA's insistence on universal coverage as an essential element of reform even as alternatives to the Clinton plan in Congress fell short of that goal. In March a delegation of Catholic health professionals led by Sr. Bernice Coreil, DC, of the Daughters of Charity National Health System, gathered at the White House with the president and first lady. In remarks to the Clintons, Sr. Coreil said, "Anything less than universal coverage is ethically unacceptable."¹⁴

Aside from the issue of universal coverage, CHA and its members had other concerns with the emerging legislation. In a June 1994 Health Progress interview with First Lady Hillary Clinton, who had chaired the White House task force on health care, some of those concerns were raised. They included questions about the plan's coverage of a full continuum of long-term care services, the exclusion of undocumented workers and the ability of long-term care facilities to cover increased payroll costs under the employer mandate. But CHA and the ministry continued their campaign of strong support for reform efforts in the hopes that legislative fixes would address any concerns. Despite that support from CHA and other organizations, the momentum for the Clinton plan faced a mountain of opposition from inside and out of Washington. The Health Insurance Association of America strongly opposed the Health Security Act and produced an infamous advertisement that helped shift public opinion against the bill. The powerful Democratic chair of the Senate Finance Committee, Daniel Patrick Moynihan of New York, also turned against the plan. The intense public campaign by opponents of the Health Security Act and competing plans from several members of Congress continued to hinder the bill's prospects through the summer of 1994. By August, congressional leadership realized that the legislation was all but dead, and it was never considered on the floor of the House or Senate.

The defeat of the Health Security Act and other proposals to reform the system in 1994 were not only setbacks for those particular pieces of legislation. The messy process, vocal opposition and overwhelming defeat of the president's party in that year's midterm elections gave many in Washington the impression that overarching health care reform was political poison. In fact, it would be well over a decade before another serious attempt at health care reform was attempted. Prior to that, Washington did take up some smaller-scale health care bills that would improve coverage for many Americans. In 1996, the Health Insurance Portability and Accountability Act or HIPAA was passed and signed into law. While HIPAA is largely associated with the regulation of medical records, the bill also contained important provisions that limited the ability of insurance companies to deny treatment for pre-existing conditions. And as the decade progressed, some of the pressure for health reform coming from spiraling health care costs was eased by the increasing reliance on managed care by insurers. That trend was recognized in the January-February 1997 issue of Health Progress, which contained a special section focusing on managed care and its implications on patients in Catholic health settings.

One of the most notable achievements in health reform from the 1990s was reached in 1997, when Sens. Edward Kennedy, D-Mass., and Orrin Hatch, R-Utah, worked together to produce a bipartisan expansion of coverage for children. The Children's Health Insurance Program, (referred to as SCHIP or CHIP), expanded coverage to millions of children and pregnant women and is still in existence today. CHA has been an ardent supporter of the CHIP program since its inception and undertook a vigorous campaign to urge reauthorization of the program in 2007 and again in 2017.

Just a few years after the CHIP program was created, Congress considered coverage expansion for seniors in the Medicare program. Since its creation in 1965, seniors in the Medicare program had not received coverage under it for prescription drugs. But by the early 2000s, prescription drugs had become a key component in maintaining the health of seniors and also had become for many the most expensive item in their care regimens. In 2003 Congress passed the Medicare Modernization Act, adding a prescription drug benefit as the program's Part D. From a political standpoint, the creation of Medicare Part D marked the first time that a major coverage expansion was passed by a GOP Congress and approved by a GOP White House. With Republicans and Democrats joining together to expand coverage for children and seniors, hope for more comprehensive health reform gained momentum. And CHA began to mobilize the Catholic health ministry to play a pivotal role in sustaining that momentum.

In the May-June 2005 edition of Health Progress a new column debuted with updates on a CHA initiative called Covering A Nation. Over the next several years, the CHA initiative worked to engage the Catholic health ministry in creating a national dialogue around health reform and to reach out to other organizations to form coalitions and partnerships advancing the same cause. The need was obvious as the rate of uninsured Americans continued to rise. By 2006, the uninsured rate stood at an all-time high of 15.8 percent. For the first time since the start of the CHIP program in the late 1990s, the number of uninsured children also rose that year.¹⁵ As the election year of 2008 approached, CHA once again undertook a spirited effort to engage the Catholic health ministry for action around health reform. In the March-April 2008 Health Progress CHA introduced Our Vision for U.S. Health Care, a collaborative effort outlining six principles based on Catholic social teaching that would be necessary for health reform to be successful. CHA's efforts were mirrored in the presidential campaign that year as the candidates outlined their plans for health reform, most aiming to achieve universal coverage. For the first time since the failure of the Clinton plan, the prospect of major health reform in Washington seemed to be in reach.

AFFORDABLE CARE ACT
The passage of the Affordable Care Act, and CHA's role in that process, is well-known to many readers. As had happened in 1965 and 1993, a new administration came into power in 2009 with a president who had made health care reform a feature of his campaign and a Congress firmly in control of the president's party, making legislative action more likely. Like Johnson and Clinton, President Barack Obama pivoted quickly to health care in his first year in office in order to take advantage of the momentum for reform. CHA's mobilization around that effort and its Covering a Nation campaign positioned the Catholic health ministry to be a key advocate for reform as Congress began to consider the legislation that would eventually result in the ACA.

The January-February 2009 Health Progress was fully devoted to the topic of health care reform and its very real prospects in Washington. Over the next few months, the various House and Senate committees with jurisdiction over health care issues began working on the various pieces of reform legislation and at least in the beginning, in a mostly bipartisan manner. But by the summer of 2009, proposed legislation became a deeply partisan and divisive issue. CHA continued to advocate generally for the reform efforts to keep moving forward and shared the ministry's Vision for U.S. Health Care with members of Congress throughout the process. In the fall, the enthusiasm and momentum had largely dissipated and legislative wrangling left the prospects of passing a bill more uncertain. The September-October 2009 Health Progress reported on the events in Washington and noted three major sticking points in the emerging legislation: whether or not to include a government plan or "public option" to compete with private insurers on the legislation's proposed health insurance exchanges; efforts to cut health care spending, particularly in the Medicare program, that had aroused intense public debate; and the issue of abortion coverage and conscience protections, perennial issues that CHA had addressed throughout the legislative progress.

These issues continued to plague the prospects of the bill in the House, now known as the Affordable Health Care for America Act. Despite their large majority, the defection of a sizable group of House Democrats from supporting the bill posed a serious threat to the reform effort. But there were some significant factors that made this time different from earlier attempts. Unlike the Clinton plan, this effort had the support of a wide array of health care organizations including CHA. On November 7, 2009, as the bill was being debated in the House, CHA wrote in support of the legislation. That support was credited by many in Congress and the administration as being decisive, given that the legislation passed with only a bare majority of 220-215. Had the bill failed in the House the reform effort would undoubtedly have stalled, and given the reticence to address the issue following the failure of the Clinton plan that probably would have ended the prospects of health care reform for years to come. The ACA still had several more hurdles to overcome, but by the spring of the following year the bill had passed both the House and Senate and was signed into law. The May-June 2010 Health Progress noted, "… Catholic health care moved the dialogue forward in a profound and historic way."¹⁶

REPEAL AND REPLACE
Following passage of the ACA, CHA's advocacy efforts turned to the law's roll-out and implementation. In the fall of 2010, Washington's political landscape was altered by the election of many new members of Congress who had run campaigns advocating repeal of the ACA and replacement with what they believed to be a more market-oriented and patient-centered approach to health coverage. For organizations that had championed the passage of health care reform, the next several years would see their focus turn to efforts to defend the new law and ensure that any of the expected coverage gains would be preserved.

Congressional foes of the ACA pointed to its low popularity in polls and hiccups in its implementation — particularly the disastrous debut of the health care exchange's website in the fall of 2013 — as proof that the law needed to be repealed. By this point the issue of health reform had become completely engulfed in a partisan battle over those who supported full implementation of the ACA and those who advocated "repeal and place." With the Senate still in the hands of a Democratic majority and Obama's re-election in 2012, the ACA was safe from congressional repeal for the time being. But the law also was challenged in the courts, most famously in lawsuits that reached the Supreme Court in 2012 and threatened the continued existence of the ACA. In June the court narrowly affirmed the power of Congress to enact most provisions of the law including the individual mandate. But the decision also dealt a blow to one of the ACA's core provisions, the expansion of the Medicaid program to provide care for low-income families and individuals, making it a voluntary effort to be decided state-by-state. CHA became a key advocate for Medicaid expansion during this period. As CHA President and Chief Executive Officer Sr. Carol Keehan, DC, noted in the March-April 2013 Health Progress, "If community voices are loud enough about demanding the Medicaid expansion, the legislative machine will respond. The people in Catholic health care should be those voices."¹⁷ Despite the temporary reprieve of the Supreme Court decision, congressional efforts to repeal the law continued in earnest. By early 2016, the House had voted for various ACA repeal measures over 60 times, efforts which now also had Senate approval. Only a presidential veto saved the law, but that would change later in the year after Republican Donald Trump was elected with GOP majorities in Congress, all of whom had committed themselves to the repeal and replace strategy toward the ACA.

CHA's advocacy efforts became almost wholly defensive following the 2016 election. Its advocacy program also shifted during this period to a greater emphasis on member engagement and direct advocacy. CHA had implemented a direct advocacy or "grassroots" program capability in the early 2000s called "e-Advocacy," which took advantage of the rise in the use of electronic messages to allow CHA members to contact congressional offices remotely with messages, including some based on sample letters provided by the association. The e-Advocacy program initially served as a small supplement to CHA's face-to-face advocacy efforts on Capitol Hill, but by the time health reform became a serious possibility programs like this had become major features of most nationwide advocacy organizations. As the new Congress and administration began considering legislation to repeal the ACA, the Catholic health ministry was poised once again to become a key player in the nation's health care debate. Through the course of the year, various repeal bills made their way through the House and Senate while facing fierce and sustained opposition from a wide array of health organizations, including CHA. The proposed devastating cuts to Medicaid drew particular opposition, and even with GOP control of Congress the bills became bogged down in intra-party squabbling and disagreements between the House and Senate. The lobbying efforts of CHA staff and Catholic health systems and facilities nationwide were reinforced by the largest grassroots campaign in the association's history. Online advocates generated nearly 7,500 messages to Congress to oppose the repeal bills, and CHA's e-Advocacy program gained over 2,500 new users in 2017 alone. By July of that year, congressional leadership was forced to scale back their repeal efforts to legislation known as the "skinny repeal," the Health Care Freedom Act. It was defeated in the Senate by one single vote. While legal and legislative threats to the ACA remain as of this writing, it has survived so far due to the vigorous and sustained advocacy efforts of organizations like CHA and our partners in the Catholic health ministry.

REFLECTIONS
In reflecting on the past century of health reform efforts in the U.S. and the Catholic health ministry's role in them, it is not only striking how much has changed but also what remains the same. It seems that no health reform effort, regardless of its origins, can fail to ignite passionate and partisan responses. The American public also remains generally uneasy at the prospect of major changes to the current health care system, even when that system is costly and leaves so many behind. At the same time, once reform has been enacted it becomes a pillar of that system, even for many who initially opposed it. It is difficult now to imagine a U.S. health care system that offers no coverage for seniors, children or low-income families and individuals, or one that still denies coverage for preexisting conditions.

But it is what has changed that makes this history notable, and hopefully signals even greater things to come. The growing awareness among health care providers and provider organizations of the need for bold and innovative reforms to the system has made an enormous difference in the most recent efforts. CHA in particular has evolved from being mostly on the sidelines during the earlier reform efforts to becoming a fully engaged partner in Washington's health care efforts. When Hospital Progress first appeared, non-Catholic Americans were largely suspicious of the church's teachings and traditions and tried to limit Catholic participation in public life. Now CHA and the Catholic health ministry have become key resources for members of Congress and the executive branch of all faiths and traditions on Catholic social thought and its implications for a just and equitable health care system. And when we speak of the CHA's influence and efforts in advocacy, we do not mean just the organization itself but the entire people of Catholic health care making their voices heard in Washington and throughout the nation. These are all developments that make us look forward to another century of Health Progress and our collective advocacy efforts.

CLAY O'DELL is director, advocacy, the Catholic Health Association of the United States, Washington, D.C.

1. Wilbur J. Cohen, "Edwin E. Witte — The Beginnings of Social Security," originally from the Industrial and Labor Relations Review 14, no. 1 (1960).
2. "Social Security History," Social Security website, https://www.ssa.gov/history/corningchap3.html.
3. Lyndon B. Johnson, "Annual Message to Congress on the State of the Union," from Jan. 4, 1965, The American Presidency Project.
4. George E. Reed, "The President's Health Message," Hospital Progress 46, no. 2 (January 1965): 48.
5. George E. Reed, "Medicare Amendment," Hospital Progress 46 no. 6 (June 1965): 10.
6. "A.M.A. Criticizes Medicare in Ad," The New York Times, June 9, 1965, 25.
7. 7. Harris Poll, The Washington Post, March 8, 1962, A2. See also Public Opinion and the Passage of the Medicare Bill blog, Roper Center for Public Opinion Research, Feb. 22, 2017.
8. Bruce C. Vladeck, Paul N. Van de Water and June Eichner, eds., Strengthening Medicare's Role in Reducing Racial and Ethnic Health Disparities, (Washington: National Academy of Social Insurance, 2006).
9. Charles N. Oberg and Cynthia Longseth Polich, "Medicaid: Entering the Third Decade," Health Affairs 7, no. 4 (Fall 1988).
10. Entry about CHA history for The New Catholic Encyclopedia from the CHA archives, sent to the Catholic University of America (July 1978): 9.
11. David Von Drehle, "Clinton Fleshes Out Health Care Proposal," The Washington Post, Sept. 25, 1992.
12. William Cox, "The Clinton Election: Implications for Healthcare," Health Progress 74, no. 1 (January-February 1993): 18.
13. "Reform Update," Health Progress 75, no. 1 (January-February 1994): 6.
14. "Reform Update," Health Progress 75, no. 4 (May 1994): 7.
15. "Number and Percentage of Americans Who Are Uninsured Climbs Again in 2006," Center on Budget and Policy Priorities, Aug. 31, 2007.
16. Jeff Tieman, "Health Reform Update – Quite A Moment, Health Progress 91, no. 3 (May-June 2010): 5.
17. Sr. Carol Keehan, "New Benefits Ahead — People Need to Know," Health Progress 94, no. 2 (March-April 2013): 2.