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 PUBLIC THEN AND NOW 

Health Care Reform and Social Movements in the

| Beatrix Hoffman, PhD

Because of the importance of THE UNITED STATES IN THE grassroots social movements, or 20th century witnessed the flow- “change from below,” in the his- ering of social movements de- tory of US reform, the relationship manding access to the American between social movements and Dream. Women, workers, Afri- demands for universal can Americans, seniors, and wel- is a critical one. fare recipients, to name just a National health reform cam- few, organized to change a soci- ety that made them second-class paigns in the 20th century were citizens. Although each move- initiated and run by elites more ment had its leaders, each relied concerned with defending against on grassroots participation, or attacks from interest groups than “change from below”: they were with popular mobilization, and made up of ordinary people de- grassroots reformers in the labor, manding reform, often on their civil rights, feminist, and AIDS ac- own behalf.1 tivist movements have concen- Yet no movement of compara- “Toward Better National Health” is a pamphlet from the Technical Committee trated more on immediate and in- ble size or intensity has arisen in on Medical Care of the Interdepartmental Committee to Coordinate Health cremental changes than on the United States to demand uni- and Activities, published by the Government Printing Office in 1939. versal health care. Labor unions, From the US Health Activism Collection of the Institute of Social transforming the health care sys- Medicine and Community Health. tem itself. senior citizens, socialists, and other groups have certainly par- such a movement for universal manded changes in the health However, grassroots health care ticipated in campaigns to re- health care, and whether and care system. But their health care demands have also contained the design the health care system, how one may emerge now and demands were for specific seeds of a wider critique of the but the campaigns themselves in the future. changes on behalf of their partic- American health care system, lead- have most often been initiated This article brings together ular group, such as racial deseg- ing some movements to adopt and run by elite some recent historical depictions regation of hospitals, access to calls for universal coverage. and with little con- of struggles for universal health abortion, and the release of ex- nection to a popular base of sup- care in the 20th century, with an perimental AIDS drugs. These port. Public opinion has generally emphasis on the role of popular grassroots demands have not co- run in favor of health care re- mobilization—or lack thereof—in alesced into a movement for uni- form, but popular approval has these struggles. It offers a new versal health care. In fact, some not been matched by the rise of understanding of social move- scholars and reformers have seen a large-scale, activist popular ments and . such small-scale improvements in movement for change.2 Because Many grassroots movements, in- health care delivery as impedi- of the importance of grassroots cluding the civil rights and ments to, or distractions from, movements to reform in the women’s movements and those more comprehensive reform. United States, it is important to on behalf of people with particu- But grassroots health care de- ask why there has never been lar like AIDS, have de- mands have also contained the

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seeds of a wider critique of the pers, president of the American march and rally on the state capi- The Great Depression was a American health care system. Ac- Federation of Labor (AFL), tol, their demands included com- time of extraordinary popular up- tivists who worked for immediate thought workers should win their pulsory health . heaval, as , workers, the and particular changes found that own benefits through union or- A somewhat bewildered AALL unemployed, veterans, elderly their experiences with health care ganizing rather than government gratefully accepted this popular Americans, socialists, and commu- led them to a new and urgent un- action; he denounced the AALL support, which led to their cam- nists organized and marched in derstanding of the need for major for neglecting labor’s opinion paign’s first and only victory: a the streets and on Washington reform, and some eventually in- and directed his membership to majority vote in the New York calling for relief and justice.6 The corporated demands for universal oppose the plan as elite paternal- Senate. But when the powerful demands of these New Deal–era access as part of their social ism. The health reformers chose speaker of the house (antisocialist social movements centered on movement agendas. By combin- a strategy of research and lobby- campaigner Thaddeus Sweet) economic security for workers and ing the history of national reform ing rather than political organiz- killed the bill in committee, the the aged; at the height of the de- campaigns with that of grassroots ing; expertise, not popular pres- first campaign for health insur- pression, the ravages of unemploy- activism for changes in the health sure, would be their tool of ance was over. Cooperation be- ment and national economic col- care system, we can better see persuasion. AALL leaders felt tween elite reformers and popu- lapse commanded more how these 2 types of movements that the most important con- lar movements had been too little immediate attention than did the have been kept apart, and also stituency for their bill was the and come too late to overcome a cost of medical care. For example, how they might come together. medical profession, and they united opposition of physicians, the Lundeen bill, an alternative to spent much of their energy per- businesses, insurance companies, the Social Security Act drafted by TWENTIETH-CENTURY suading doctors to support the and conservative legislators intent Minnesota’s radical –Labor CAMPAIGNS FOR HEALTH legislation—a cause that turned on branding Party, outlined a program of social CARE REFORM out to be futile in the face of “Bolshevism.”4 insurance for all workers, includ- practitioners’ fears that compul- The emphasis of health reform ing wage replacement for those Early in the 20th century, in- sory insurance would erode their shifted during the 1920s as med- “unable to work because of sick- dustrial America faced the “prob- incomes and independence.3 ical care became both more effec- ness,” but it made no mention of lem of sickness”: when working When reformers did look to tive and more expensive; soon, medical care or health insurance.7 people missed work owing to ill the popular movements of the medical costs and access to care With crowding out health, they also lost their wages. Progressive Era, they found sub- replaced wage support as reform- health care as a social movement This loss of income, even more stantial support for health insur- ers’ primary concern. But the priority, health reformers needed than the cost of medical care, ance. The Socialist Party had en- character of reform to make a concerted effort to per- made sickness a major cause of dorsed a compulsory system as changed little, and health reform- suade social activists to join their . In 1915, progressive re- early as 1904, and in 1912 ers continued to share the elite crusade. formers proposed a system of Theodore Roosevelt’s insurgent status of their predecessors. The But New Deal health reformers compulsory health insurance to Progressive Party included a most prominent reform group of remained out of touch with the protect workers against both health insurance plank in its the 1920s, the Committee on the grassroots. In the 1930s, some wage loss and medical costs dur- campaign platform. In New York Costs of Medical Care (CCMC), CCMC leaders became political ing sickness. The American Asso- and California, local labor lead- which was financed by large insiders as they joined the com- ciation for Labor Legislation’s ers defied the AFL’s directive and foundations and made up of mittees charged by President (AALL) proposal, modeled on ex- threw their support behind the physicians, academic economists, Franklin D. Roosevelt with creat- isting programs in and AALL’s plan, arguing that health and representatives of private in- ing proposals for health care to England, was debated through- insurance would protect both terest groups, again relied on re- add to the Social Security Act out the and introduced workers’ health and their wages. search rather than popular mobi- (the Committee on Economic Se- as legislation in several states. Women trade unionists and suf- lization. The CCMC’s modest curity and the Technical Commit- This early campaign for com- fragists were intensely interested proposals for group medicine and tee on Medical Care). These New pulsory health insurance set a in the proposal because it in- voluntary insurance were de- Deal committees worked mostly precedent for a continuing dis- cluded maternity benefits for nounced by the American Med- in secret, isolated from public tance and lack of cooperation be- women workers. In New York in ical Association (AMA) as “social- input and debate. Their members tween reform leaders and popu- 1919, women reformers adopted ized medicine,” but the battle was were constantly on alert for at- lar movements. The AALL was a the AALL plan as part of a slate fought in the pages of newspa- tacks from the medical profession group of academic reformers of bills to protect working pers and academic journals, with and business, and this caution led who drafted their proposal with- women, and when suffragists no attempt to enlist ordinary peo- to less-than-sweeping proposals out input from the working peo- joined with the New York State ple as advocates for the reform- for health reform; both commit- ple it would cover. Samuel Gom- Federation of Labor in a mass ers’ recommendations.5 tees recommended federal subsi-

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dies to states rather than a na- union members in the battle,” By then, organized labor’s at- tional system. But even these re- historian Alan Derickson argues, tention had turned elsewhere. forms raised the ire of physicians, was “a crucial flaw in the cam- Unions were increasingly win- and Roosevelt so feared attacks paign for health security.” Both ning health benefits for their by the AMA that he dropped AFL and CIO leaders, aiming for members through collective bar- health coverage from his New a place in the postwar power gaining agreements with employ- Deal agenda.8 Because New Deal structure, “discouraged rank-and- ers, so the need for national re- insiders did little to win grass- file initiatives” and “never consid- form seemed less urgent. The roots participation and support, ered grassroots mass mobiliza- failure of national health legisla- their cautious and technical pro- tion.” The lack of rank-and-file tion further encouraged labor to posals for health care restructur- participation greatly weakened ing failed to capture the imagina- the cause of union-led health re- Because New Deal insiders did little to win tions of ordinary Americans. And form as it became associated grassroots participation and support, without pressure from a strong with “union bosses” rather than their cautious and technical proposals for social movement on behalf of ordinary workers. The other “ medical insurance, Roosevelt major reform backer, the Com- health care restructuring failed to capture bowed to the AMA rather than to mittee for the Nation’s Health, a the imaginations of ordinary Americans. health reformers. successor to the CCMC with In the 1940s, new potential for many of the same members, also pursue private solutions, while grassroots mobilization arose decided not to solicit grassroots these solutions themselves, by when organized labor became a participation on behalf of the meeting the needs of at least major backer of national health Wagner–Murray–Dingell bill, ar- some of America’s workers, ” insurance. As the cost of medical guing that it lacked the funds to made it more difficult to argue care began eating up more of the organize local branches.9 for systemic change. Organized average worker’s budget, both the Reformers needed all the help labor would continue to be a AFL and the Congress of Indus- they could get to fight an un- major supporter of universal trial Organizations (CIO) took precedented onslaught by the health care proposals, particu- leadership roles in the struggle for AMA. After Truman’s electoral larly through Walter Reuther’s health reform. In 1943, labor victory in 1948, the doctors’ or- Committee for National Health unions joined the reformer- ganization spent over $1 million Insurance in the 1970s. But, “be- experts of the Committee for the on an anti–health reform public cause most of the working-class Nation’s Health and liberal ad- relations blitz that included ad- constituency for ministration officials in drafting vertising, television and radio had been accommodated the Wagner–Murray–Dingell bill spots, telegram and letter-writing [through private coverage], the (named for its congressional spon- campaigns, and the lobbying of potential for building a mass sors), the major health insurance legislators by their own personal movement . . . dwindled.”12 legislation of the Truman era. physicians. Unlike reformers, Possibilities for grassroots mo- This bill proposed a national med- AMA members successfully bilization resurfaced in the ical insurance program financed reached out to the grassroots with 1960s during the debate over through social security payroll “doctor-to-patient” letters de- Medicare. Health reformers had taxes, and it enjoyed the strong nouncing the Wagner–Murray– been working on a plan for med- support of Harry S. Truman. Dingell bill.10 And in the midst of ical coverage of the elderly for a During the struggle over Wag- the Cold War, health reformers’ decade when the idea was ner–Murray–Dingell, the oppor- insider status made them vulnera- adopted by John F. Kennedy and tunity to mobilize a broad-based ble to opponents who saw a So- his successor, Lyndon Johnson. movement was once again lost. viet-inspired conspiracy for “so- The outpouring of civil rights ac- Labor leaders and policy intellec- cialized medicine” at the very tivity in the early 1960s spurred tuals believed they could make heart of the federal government. politicians to support Medicare change from within the system Prospects for the passage of the as part of Johnson’s War on Pov- and so did not need the orga- health bill vanished when most of erty, and major civil rights nized activity of union members its congressional supporters were groups all endorsed the legisla- to back up their efforts. The “fail- unseated in 1950 with the help tion.13 Organized labor was ure of union leaders to enlist of the AMA’s campaign.11 again a strong supporter of

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health reform, not just to ensure co-sponsored by Senator Edward serve both employer-based cov- mobile Workers and the Ameri- care for the uninsurable but also Kennedy. erage and the commercial insur- can Federation of State, County “to eliminate the increasingly The CNHI reached out to an ance industry. Advocates for uni- and Municipal Employees, costly problem of negotiating impressive number of civil rights versal health coverage argued balked: they did not want to be health benefits for [union] re- and antipoverty groups, but still that this model would increase seen as attacking the new Clinton tirees.” The AFL-CIO created the relied on professional staff, con- the power of private insurers and administration, which depended National Council of Senior Citi- ferences, and Washington-based take away patients’ choice of on labor support. Like other zens, made up of retired union lobbying, not on grassroots ac- doctors. One physician-activist labor leaders before them, union members, to publicly campaign tivism. Comprehensive reform dubbed the plan the “Health In- officials “reportedly told other for Medicare. The was again weakened by interest- surance Industry Protection Act health care activists that they soon expanded to include other group squabbles; the CNHI bill of 1993,” and another agreed would only work from ‘inside’ retiree groups. The council competed with 13 other health that managed competition “won’t the Clinton team to influence the launched petition drives and let- insurance proposals, including control costs and the entire course of health reform.”20 With- ter-writing campaigns and, writes ones sponsored by the AMA and health care system will be owned out a mass base of support, the sociologist Jill Quadagno, “en- commercial insurance compa- by a handful of insurance Clinton Health Security bill fell deavored to create the sense of a nies, and reform lost momentum giants.”17 And the nearly 1400- before its powerful and well- grassroots political movement.” when the massive health care in- page proposal was far too com- financed opposition. Retirees disseminated “millions” of flation of the 1970s led to an plicated and confusing to inspire This brief overview of some pieces of literature in an attempt emphasis on cost control rather a popular movement on its be- 20th-century reform efforts re- to thwart AMA propaganda, and than on expanding coverage.16 half; activists concluded that “few veals that 2 major explanations 14 000 seniors marched down the But as the number of uninsured could, or should, rally to this for their defeat—the power of pri- boardwalk at the 1964 Democra- began to rise in the 1980s, pub- banner.”18 vate interest groups to block re- tic Convention in Atlantic City.14 lic discontent intensified. In While the mainstream AFL- form and reformers’ failure to in- Americans were highly sympa- 19 92, when Bill Clinton rode CIO approved the Clinton plan spire grassroots activism—are thetic toward the elderly as a into the White House on a wave for meeting its goal of worker inextricably connected. The re- group, which made it harder for of popular support for major coverage through an employer lentless opposition of medical, the AMA and other opponents “to changes in the health care sys- mandate, many grassroots organ- business, and insurance interests engage in open warfare” against tem, the potential for mass mobi- izations supported more com- pushed reformers to design health reform, and in July 1965 lization around universal cover- prehensive, universal reform health care proposals around pla- Medicare became part of the So- age had never seemed greater. modeled on the Canadian “sin- cating their opponents more than cial Security Act.15 But again, the opportunity was gle-payer” system, in which tax- winning popular support. In turn, The organization of senior cit- squandered. The Clinton admin- funded government payments to ordinary people had trouble ral- izens on behalf of Medicare sig- istration relied on the same elite- providers would replace em- lying around complex proposals naled the rise of a significant based decisionmaking that had ployer health benefits and the that emphasized administrative new reform constituency. Al- isolated previous reform efforts private insurance industry. The design and federalist fragmenta- though initiated by trade unions, from grassroots influence. Ac- Gray Panthers, the Consumers’ tion rather than a universal right the pro-Medicare retiree groups tivists complained that the secre- Union, mental and public health to basic health care. succeeded in mobilizing ordi- tive Clinton Health Care Task groups, and progressive labor None of these major reform at- nary senior citizens who sought Force, made up of policy experts unions decided to back an alter- tempts was initiated or fought health reform based on their and led by Hillary Clinton and native single-payer bill in Con- primarily at the grassroots level. own experiences in a system that the president’s close friend Ira gress, and the group Citizens’ Ac- The problem in 1994 was not denied them insurance coverage. Magaziner, “completely con- tion organized supporters to send much different from that in Even after Medicare’s passage, trolled” the drafting of the Health 1 million postcards favoring a 1949 or 1918: reformers put which may have quieted some Security bill and only later single-payer system to the White their faith in expertise and pro- discontent among the elderly, turned to citizen groups asking House.19 But the single-payer fessional lobbying rather than seniors continued to be major for support “for a plan that coalition was divided and weak- popular activism. Writing on the supporters of reform. In the they’ve already written.”16 ened by its groups’ varying com- defeat of 1940s health legisla- 1970s the National Council of And the plan itself dismayed mitments to grassroots organiz- tion, Alan Derickson argues that Senior Citizens and other sen- potential supporters. Clinton, ing. Some labor unions wanted “[b]y relying on . . . progressive iors’ groups joined the labor-led fearful of business and insurance to run a vigorous campaign in- lobbying groups” such as the lib- Committee for National Health company opposition, proposed a cluding mass mailings and a eral Physicians Forum, reformers Insurance (CNHI) and worked dauntingly complex system of cross-country bus caravan, but 2 “unwittingly contributed to the hard for the passage of a plan “health alliances” that would pre- powerful unions, the United Auto- perception that the goal of uni-

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versal health care, an element of the general welfare, was merely an object of interest group ma- neuvering.” Another scholar points out that during the Clinton health campaign, the reform en- vironment was “dominated by advocacy groups,” professionally run organizations mostly based in Washington, that were “accus- tomed to insider lobbying rather than popular political mobiliza- tion.”21 Important as they are in the US , coalitions of professionalized reform groups are not the same thing as peo- ple’s movements.

GRASSROOTS MOVEMENTS AND HEALTH CARE REFORM

There has been a gap be- tween health care reformers and cine, and the activism of particu- mands could be fully realized Members of Disabled in Action their potential constituencies, a lar groups of patients, including only with universal access to lead a march through downtown Philadelphia sponsored by Health gap that has created a significant people with AIDS, breast cancer, health care. A recurring theme Care for All/Philadelphia, on April obstacle to popular mobilization and . of health care activist move- 22, 1992, demanding that the can- on behalf of universal health These types of activism have ments has been the broadening didates for US president endorse a care. But a large part of the story ostensibly focused on a single of their single-issue and particu- universal and comprehensive single- still needs to be told. If we stop issue (such as abortion or deseg- lar demands to include funda- payer health insurance plan. Photograph by Julie Davids. using only the well-known cam- regation) or on demanding bene- mental change in the US health Courtesy of the Institute of Social paigns for national health cover- fits for one particular group care system. Medicine and Community Health. age as a yardstick, grassroots ac- (such as AIDS patients or the This theme can be traced as tivism and social movements for disabled). The reforms they ad- far back as 1913, when the Inter- health care reform become vocated, and in many cases won, national Ladies’ Garment Work- much more apparent. made important changes in the ers’ Union (ILGWU) established By grassroots health care ac- health care system but, arguably, a Union Health Center in New tivism, I mean movements that did not alter the nature of the York City to treat urban clothing include, and are sometimes led system itself. These movements, workers, who had a high inci- by, patients or potential health then, might be described as part dence of tuberculosis and other care consumers, themselves. As of the tradition of pluralism or health problems. The Union opposed to elite health reform, incrementalism in American Health Center was different from which has relied on research and health , which has gener- physician- and employer-initiated expertise, health care activism is ally been seen as an impediment clinics in that it was created and rooted in people’s experiences to large-scale reform.22 But the staffed by those who would be with the health care system. Ex- dichotomy between particular using the health care themselves. amples from the 20th century in- and universal reform is some- As the union members who ran clude workers’ attempts to estab- times a false one. Through their the center cared for workers’ im- lish medical cooperatives and experiences in the medical sys- mediate health problems, they clinics, civil rights activists’ de- tem and also their experiences came to see the need for more mands for greater racial equality with activism, members of social universal provision. in health care, feminist chal- movements for health reform re- Former garment worker Paul- lenges to gender bias in medi- peatedly concluded that their de- ine Newman, who headed the

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Union Health Center for 5 munity public health move- formed the Medical Committee medical profession than for its decades, argued that union-run ments.25 And civil rights activists on in 1964 to advocacy of universal access. Yet health care threw into sharp re- rightly distrusted reform propos- give medical aid to civil rights feminists early on drew connec- lief the vastly greater needs of als that either explicitly main- workers in the South, but they tions between the nature of the the unorganized. “[T]he great tained segregation or ensured in- quickly became involved in fight- health care system and its treat- mass of workers are not in any equality by other means, such as ing “inadequacies in health care” ment of women. In 1971, the position to look after their own giving states control over health in the North as well.28 After win- first edition of the feminist clas- sickness and their own prob- provision. The National Associa- ning the hard-fought battle for sic Our Bodies, Ourselves argued lems,” said Newman in 1917. tion for the Advancement of Col- hospital integration in the mid- that profit-driven medicine had “That is why [the ILGWU] is in ored People (NAACP), for exam- favor of health insurance and so- ple, supported the Wagner– The activism of people with AIDS and HIV cial insurance. We can take care Murray–Dingell bill only reluc- fighting for their very lives led to of ourselves, but who are we? A tantly because the proposal mere hundred and fifty thou- lacked “‘safeguards’ to ensure unprecedented changes in the sand.” Newman and the ILGWU ‘equitable distribution of funds in “ health care system. were the most active union sup- the states where Negroes and porters of Progressive Era com- whites [were] forced to use sepa- 1960s, civil rights activists con- led to an epidemic of unneces- pulsory insurance proposals, and rate hospitals, clinics and other fronted the daunting problems sary hysterectomies while Newman continued to advocate health services.’” Decades later, still faced by low-income African women without” access to pri- for the rest civil rights organizations feared Americans in getting medical mary care died of preventable of her long life. Similarly, the that some aspects of Clinton’s care. Hospital limitations on care cervical and uterine cancers. Western Miners’ Federation, Health Security bill, including the for the poor, and the refusal of The authors declared, “We be- which established a worker-run emphasis on employer-sponsored many hospitals and physicians to lieve that health care is a human hospital system early in the cen- coverage and the inclusion of pri- accept Medicaid, demonstrated right and that a society should tury, passed strong endorse- vate insurance companies with the link between economic and provide free health care for it- ments of compulsory health in- their long history of racial racial barriers to access. Civil self. Health care cannot be ade- surance in the 1910s.23 Unlike in “redlining,” might hurt African rights groups initiated a series of quate as long as it is conceived the post-1945 era, these private Americans.26 class-action suits demanding that of as insurance. . . . Health care benefits schemes did not draw Still, the goal of universal health federally financed hospitals ac- for everyone is possible only out- unions’ energies away from ad- care has been an integral part of cept more poor patients and con- side of the profit system.”31 vocating broader reforms; rather, civil rights agendas. For many civil tinue to serve inner-city neigh- Feminists’ demands for safe they inspired a comprehensive rights activists, the fight against borhoods rather than fleeing to and legal abortion have been critique of a health care system segregation was inseparable from the suburbs.29 As Black commu- portrayed as emphasizing indi- that left so many workers with- demands for national health care. nities were ravaged by epidemics vidual rights, especially since the out access to medical care or Physician and NAACP leader Dr of hypertension, diabetes, and in- Supreme Court based its Roe v sick pay. Montague Cobb in 1947 called fant mortality, national civil Wade decision on a “right to pri- Civil rights activism has often for the National Medical Associa- rights organizations helped local vacy,” which some scholars have been at odds with elite-led cam- tion, the organization of Black activists set up neighborhood argued precluded the establish- paigns for health reform. Progres- doctors, to attack racial discrimina- health clinics and demonstration ment of a “medical entitlement” sive Era and New Deal reformers tion in medical care, and also de- projects. Like union clinics earlier to abortion.32 But abortion rights deliberately left the mostly Black manded a “vigorous and forthright in the century, the local health activism could lead to a broader agricultural and domestic work- confirmation” of national health care projects of the 1960s and critique of the health care sys- force out of their schemes, and insurance. The NAACP, the Na- 1970s worked not only to ad- tem. In one example, the Young the Committee on the Costs of tional Medical Association, and dress immediate needs but also Lords Party, one of the few Medical Care excluded Black the Urban League have been to spread the idea of universal Puerto Rican nationalist organi- households from its studies.24 For longtime, if critical, supporters of access—the idea that, as one zations to support abortion ac- much of the 20th century, racial proposals for universal medical Urban League clinic poster cess, vocally protested the 1970 deprived African coverage.27 stated, “Good health is a right, death of a Puerto Rican Americans of basic health care Civil rights activists have rec- not a privilege.”30 during a legal abortion in a New and forced them to concentrate ognized that desegregation in The women’s health move- York City hospital. Her treatment on building their own institu- and of itself is insufficient to ment of the 1960s and 1970s is at the hands of the public hospi- tions, like fraternal societies, life bring about racial equality in better known for its powerful tal system “proved that legal insurance companies, and com- health care. Activist physicians critique of the sexism of the abortion was not the answer for

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poor and Third World women cessful, than during the AIDS cri- lem of “PWAs [people with who did not have access to qual- sis. The activism of people with AIDS] being denied access to life ity health care,” and the Young AIDS and HIV fighting for their saving services and primary Lords demanded “community very lives led to unprecedented health care” and to consider the control” of city health care insti- changes in the health care sys- question, “What are we doing tutions.33 Reproductive rights ac- tem, including speeded-up drug about the establishment of Na- tivists found that in a stratified trials, pharmaceutical price re- tional Health Care?” ACT health care system, access to safe ductions, and large increases in UP–New York’s Insurance and and legal abortion was a right in AIDS research and funding. Access Committee released the name only. AIDS activists’ targeting of re- statement, “We believe that in a The women’s health move- searchers and drug companies country with as much [sic] re- ment has greatly influenced cam- has been highly publicized and sources as we have that quality paigns for national health care. documented.35 Less noticed has health care is a right,” and in In the early 1970s, the labor-led been the AIDS community’s 19 91 it launched a publicity Committee for National Health growing concern with inequities campaign featuring a poster that Insurance held the first confer- in the health care system. read, “Lack of Insurance Kills ence on women and universal ACT UP, the radical organiza- People with AIDS: Lack of insur- health care. At that and later tion of people with AIDS and ance means lack of access to conferences, feminist perspec- their supporters founded in health care, and lack of health tives increasingly altered the re- 19 87, at first protested against care means death.”37 form agenda. Women labor lead- health and insurance AIDS activists appeared to ers and others noted that the companies with HIV exclusions have won a major victory in majority of the underinsured and in their policies. But even when 1990 with the passage of the ACT UP Records, 1993, Manuscripts uninsured were women, and that some of this blatant discrimina- Ryan White CARE Act, which and Archives Division, New York employment-based health cover- tion was curbed, most people provided significant financing for . age implicitly discriminated with AIDS and HIV still could against women, who were heav- not get access to private insur- ily concentrated in sectors with ance because of its extraordinar- no benefits: part-time, temporary, ily high cost. ACT UP’s New York , and small business em- branch formed an Insurance and ployment and homemaking. Fem- Access Committee to fight insur- inists criticized the health care ance rate increases, and activists system’s emphasis on high-tech began to target insurance compa- hospital treatment at the expense nies with highly visible “street of primary and preventive care. theater” actions, including civil During the Clinton health reform disobedience in front of insur- campaign, the Older Women’s ance headquarters in New York League organized a Campaign and the National Insurance Asso- for Women’s Health to demand ciation in Washington, DC. that health reform include pri- When increasing numbers of mary, preventive, and long-term people with AIDS were forced to care and coverage for mental turn to Medicaid, ACT UP health, HIV testing and counsel- worked to expand Medicaid ben- ing, screening, efits to include important AIDS and full reproductive health care services and treatments.36 and planning. Several of Activists soon became frus- the women’s demands were in- trated with these incremental im- corporated into the Health Secu- provements and began to argue rity bill.34 for deeper change in the health At no time has the connection care system. At a “People of between grassroots movements Color AIDS Activist Conference” and health care reform been in 1990, participants were asked more powerful, and more suc- to address the continuing prob-

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AIDS services, including primary TOWARD A SOCIAL ment. And immediate, local, and health care. But conservatives in MOVEMENT FOR incremental reforms have been Congress initially refused to re- UNIVERSAL HEALTH CARE more politically feasible than lease the funds, using the argu- more comprehensive change. ment that “they don’t want to Even though a significant But the distance between ex- take money away from other number of grassroots movements pert and grassroots health reform people who also need it.” ACT have advocated universal health has not been insurmountable. UP, infuriated by the legislators’ care, until recently national Since the social upheavals of the stance, called for national health health care reformers have had 1960s, health care reform organi- insurance, which “should circum- few connections with these con- zations have increasingly recog- vent this debate by guaranteeing stituencies. The distance between nized the importance of grass- treatment and medical care to elite and grassroots health cam- roots participation to their cause. every American whatever they paigns, as we have seen, is partly From the Advisory need.” Only universal coverage explained by reform leaders’ lack Center, founded by New Left ac- would ensure that patients with of knowledge of, lack of interest tivists, to today’s Universal Health different diseases and conditions in, or outright exclusion of popu- Care Action Network (UHCAN), would not be pitted against each lar reform constituencies and created in the aftermath of the other. “National health care is grassroots organizing strategies. Clinton health debate, health re- just morally right,” AIDS activists But much of the explanation also formers have either emerged concluded. “That our country lies with the nature of the social from or worked closely with has gone so long without it is a movements themselves. For grassroots groups and have incor- scandal.” ACT UP and other movement activists, other de- porated community-organizing AIDS organizations joined state- mands have been more urgent, techniques to build support. Re- level and national health reform immediate, and even life-and- form proposals are still generated coalitions and organized marches death than long-term change in primarily by professional advo- on Washington to demand uni- the health care system—the right cacy organizations, but these versal health care in 1992 and to organize for the labor move- have increasingly gone beyond AIDS activists join in the April, 19 93.38 Winning increased ment, desegregation for the civil the labor–reformer coalition to 1992, Health Care for All/Philadelphia march. health care rights for some led rights movement, reproductive embrace other popular con- Photograph by Julie Davids. these grassroots activists to see rights for the feminist movement, stituencies, including public Courtesy of the Institute of Social the need for health care rights research and drug access health and social workers, nurses, Medicine and Community Health. for all. for the AIDS advocacy move- seniors, religious activists, and people with particular diseases or disabilities. While physician health reformers from the 1910s through the 1950s based their appeals on their expert status rather than popular mobilization, reformist doctors now reach out to the wider community as much as to their fellow professionals. The most prominent medical re- form organization, Physicians for a National Health Program, founded in 1987 to advocate a single-payer health system, em- phasizes its members’ efforts to “work closely with grassroots con- sumers’, seniors’, and disability rights organizations.”39 Since the end of the Clinton health care campaign, public dis- content with the medical system

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and frustration with traditional headquarters. “Shouting and car- have dropped Medicare enrollees, reform efforts have led to an up- rying signs,” the “largely young and as some doctors have begun surge in state-level grassroots ac- crowd” chanted “Hey hey, ho ho, to reject Medicare patients as too tivism. Health reform movements corporate health care’s got to go” costly. State budget crises are are currently active in over a and booed life-size puppets of in- forcing drastic cuts in Medicaid.46 dozen states, from California to surance executives. Although The workers, seniors, and poor Maryland.40 These ballot initia- statewide single-payer legislation who were formerly pro- tives and political campaigns for failed, Maine legislators plan to tected by job benefits, Medicare, universal coverage appeal to an reintroduce it in 2003.43 and Medicaid now have more in increasingly diverse support base. Today’s health care reform common with the uninsured and Organizers of Oregon’s single- movement is diverse in organiz- the underinsured. payer Health Care for All initia- ing style, membership, and tac- State-level campaigns for uni- tive, for example, have won the tics, and even in its goals. Al- versal coverage have greater po- endorsements of groups repre- though most campaigns push for tential for grassroots mobilization senting , medical stu- a single-payer system, some, in- than the “patients’ rights” propos- dents, churches, tenants, seniors, cluding UHCAN and the Mary- als currently languishing in Con- African Americans, alternative land Citizens’ Health Initiative, gress. While patients’ rights has health practitioners, women, and argue that universal coverage been described as a “consumer environmentalists, as well as could be achieved by other fi- movement” of HMO members, labor unions.41 nancing methods.44 Whatever this simply points to its limita- Even as they expand their their differences, state and na- tions. Consumer identity can be a constituencies, most state reform tional reform groups all agree powerful organizing force,47 but campaigns continue to empha- that a movement for universal basing health care demands on size coalitions of professional ad- health care must rely on grass- people’s roles as consumers still vocacy groups as the centerpiece roots mobilization and the sup- narrows the constituency for re- of their organizing strategies.42 In port and participation of local ac- form: to consume health care, contrast, the activists of Maine’s tivists. This recurring theme one must have access to it. A Citizen’s Health Initiative have appears in a recent UHCAN an- consumer-based movement is not chosen to build membership nouncement: “One key lesson necessarily more inclusive than a through door-to-door canvassing UHCAN has learned in our ten movement of seniors, of welfare of individuals rather than the en- years is that to change the health participants, of AIDS or breast dorsements of the already orga- care system, we need a nation- cancer patients, or even of the nized. Maine reformers used ally coordinated movement with uninsured and underinsured. these organizing methods, based deep roots all over the country— Like other piecemeal reforms, in the US social movement tradi- roots that extend into the faith patients’ rights only leads to the tion, to win a major victory: in community, the labor movement, question of why some, but not November 2001, Portland voters the health provider sector, and all, deserve access to health care. approved, 52% to 48%, a non- other places where people come State-level reform campaigns, binding referendum calling for together who care about health wielding slogans like “Health universal health care in the state. care justice.”45 Care for All” and “Everybody In, The referendum passed even Advocates also agree that the Nobody Out,” are working to though opponents, as usual, constituency for universal access unify, rather than separate, their greatly outspent supporters. The is growing as changes in the potential supporters. “You can’t Maine health care reform move- health care system break down build a social movement with a ment has also adopted ACT UP– some of the forces that have frag- Band-Aid philosophy,” argues style street actions to dramatize mented popular support for re- 73-year-old Ohio single-payer ac- its call for universal coverage. form. Employer cutbacks and lay- tivist and former civil rights When Anthem Blue Cross/Blue offs are heightening the instability worker Jerry Gordon. “Where Shield of Maine created an insur- of job-based health coverage. would civil rights be, with that ance-industry front group to fight Medicare’s limitations are increas- kind of attitude?”48 health reform, activists staged a ingly obvious as more people “raucous” march and rally in enter the system, as health main- front of the company’s Portland tenance organizations (HMOs)

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About the Author 5. Colin Gordon, Dead on Arrival: Insurance, see Starr, Social Transforma- Journal of Nursing 17 (1917), 943; Hoff- Beatrix Hoffman is with the Department of Health Care and the Limits of Social Pro- tion of American Medicine, 382, 404. man, Wages of Sickness, 120–123, History, Northern Illinois University, vision in the United States (Princeton, NJ: 143–146; Alan Derickson, Workers’ 13. Medicare was endorsed by the DeKalb. Princeton University Press, in press), Health, Workers’ : The West- NAACP, the National Urban League, Requests for reprints should be sent to 410; Jonathan Engel, Doctors and Re- ern Miners’ Struggle, 1891–1925 and the National Medical Association; Beatrix Hoffman, PhD, Dept of History, formers: Discussion and Debate Over (Ithaca, NY: Cornell University Press, Dona Cooper Hamilton and Charles V. Northern Illinois University, DeKalb, IL Health Policy, 1925–1950 (Columbia: 1988), 182. While physician-run coop- Hamilton, The Dual Agenda: Race and 60115 (e-: beatrix @niu.edu). University of South Carolina Press, eratives and group practice played an Social Welfare Policies of Civil Rights Or- This article was accepted September 2002), chap 2. important role in incremental health re- ganizations (New York: Columbia Uni- 16, 2002. form, they do not fit the definition of 6. See, for example, Edwin Amenta, versity Press, 1997), 155–156. Accounts Note.The views expressed imply no en- grassroots activism used in this article Bold Relief: Institutional Politics and the of civil rights support for Medicare do dorsement by the Robert Wood Johnson since they were initiated by providers Origins of Modern American Social Pol- not discuss Medicaid as a separate pro- Foundation. rather than consumers. On medical co- icy (Princeton, NJ: Princeton University gram; more needs to be done to analyze operatives, see Michael Grey, New Deal Press, 1998), 108–117; Alan Brinkley, the movement’s position on Medicaid, Medicine: The Rural Health Programs of Voices of Protest: Huey Long, Father which as a state-based program had Acknowledgments the Farm Security Administration (Balti- Coughlin, and the Great Depression (New very different implications for civil rights The research for this article was funded more: Johns Hopkins University Press, York: Random House, 1983). than did Medicare. in part by an Investigator Award in 1999), chap 2; Starr, Social Transforma- Health Policy Research from the Robert 7. HR 2827, 74th Cong, 1st Sess, 14 . Jill Quadagno, “ as Politics tion of American Medicine, 302–306. Wood Johnson Foundation. January 3, 1935. On the Farmer–Labor in Action: How the ‘Red Menace’ De- 24. Hoffman, Wages of Sickness, 29– I thank Colin Gordon and Jill Qua- Party, see Richard M. Valelly, Radicalism railed National Health Insurance,” paper 32; Gordon, Dead on Arrival, 275–283; dagno for sharing their research and in the States: The Minnesota Farmer- presented to the Department of Sociol- David Barton Smith, Health Care Di- Anne-Emmanuelle Birn, Ted Brown, Labor Party and the American Political ogy, New York University, February 21, vided: Race and Healing a Nation (Ann Alan Derickson, Liz Fee, Walter J. Lear, (Chicago: University of 2001 (in the author’s possession), 29, Arbor: University of Michigan Press, Anne S. Kasper, Corinne Sutter-Brown, Chicago Press, 1989). 32–33, 34–35, 39. 1999), 29. and 3 anonymous reviewers for their 8. Gordon, Dead on Arrival, 22–24; 15. Marmor, Politics of Medicare, 28. helpful suggestions. 25. David Beito, From Mutual Aid to Paul Starr, The Social Transformation of 16. Bob Dreyfuss of Physicians for a the : Fraternal Societies and American Medicine (New York: Free National Health Plan, quoted in Judy Social Services, 1890–1967 (Chapel Press, 1982), 269, 275–279. On New Endnotes Keen, “Health Panel’s Job: ‘Activate Hill: University of North Carolina Press, Deal health reformers, see also Engel, 1. On social movements and grass- Grass Roots’,” USA Today, March 30, 2000); M.S. Stuart, An Economic De- Doctors and Reformers, chap 3 and 4; roots activism, see Sidney Tarrow, 19 93, 1A. On the Clinton Health Care tour: A History of Insurance in the Lives Daniel S. Hirshfield, The Lost Reform: Power in Movement: Social Movements, Task Force, see Haynes Johnson and of American Negroes (College Park: Uni- The Campaign for Compulsory Health In- Collective Action and Politics (Cambridge, David S. Broder, The System: The Ameri- versity of Maryland Press, 1969); surance in the United States From 1932 England: Cambridge University Press, can Way of Politics at the Breaking Point Vanessa Gamble, Making a Place for to 1943 (Cambridge, Mass: Harvard 1994); Marco Guigni, Doug McAdam, (Boston: Little, Brown & Co, 1996). Ourselves: The Black Hospital Movement, University Press, 1970). and Charles Tilly, eds, How Social Move- 17. Quentin Young, MD, “Clinton 1920–1945 (New York: Oxford, 1995); ments Matter (Minneapolis: University of 9. Alan Derickson, “Health Security Health Plan Is No Cure,” Chicago Sun- Susan Smith, Sick and Tired of Being Minnesota Press, 1999); Temma Kaplan, for All? Social Unionism and Universal Times, September 21, 1993, 26; Russell Sick and Tired: Black Women’s Health Crazy for Democracy: Women in Grass- Health Insurance, 1935–1958,” Journal Beckley, MD, “To the Editor,” Los Ange- Activism in America, 1890–1950 roots Movements (New York: Routledge, of American History 80 (1994): 1333– les Times, November 5, 1993, B6. (Philadelphia: University of Pennsylva- 19 97). 1356 (quotes from pp. 1342–1343); nia Press, 1995). 18. Steffie Woolhandler, MD, and Gordon, Dead on Arrival, 413. 2. From 1943 to 1965, opinion polls David U. Himmelstein, MD, “Giant 26. Hamilton and Hamilton, The Dual showed that “a relatively stable two- 10. Gordon, Dead on Arrival, 339. See HMO ‘A’ or Giant HMO ‘B’?” The Na- Agenda, 73, 244–254. The quotation thirds majority of Americans” favored also Monte M. Poen, Harry S. Truman vs tion, September 19, 1994, 265–268. is from the NAACP’s Walter White. “some government role in the financing the Medical Lobby: The Genesis of 19.Adrianne Appel, “An Alternative to 27.W. Montague Cobb, “What Pur- of personal health services”; Theodore Medicare (Columbia: University of Mis- Managed Care,” Christian Science Moni- pose NMA?” August–September 1947, Marmor, The Politics of Medicare (Lon- souri Press, 1979). tor, May 18, 1993, 2. The bill was file drawer K-4, Michael Davis Papers, don: Routledge, 1970), 3. See also 11. Alan Derickson, “The House of known as Wellstone-McDermott for its New York Academy of Medicine; Hamil- Lawrence Jacobs, The Health of Nations: Falk: The Paranoid Style in American congressional sponsors. ton and Hamilton, The Dual Agenda, 77. Public Opinion and the Making of British Health Politics,” American Journal of and American Health Policy (Ithaca, NY: 20. Marie Gottschalk, “The Missing 28. David McBride, From TB to AIDS: Public Health 87 (1997): 1836–1844; Cornell University Press, 1993); Millions: Organized Labor, Business, Epidemics Among Urban Blacks Since Marmor, Politics of Medicare, 12–14. Reuters, “Poll finds momentum for radi- and the Defeat of the Clinton Health 1900 (Albany, NY: SUNY Press, 1991), cal health care reform,” August 26, 12. Derickson, “Health Security for Security Act,” Journal of Health Politics, 154. 2002, available at: http://www.ada.org/ All?” 1355. On the postwar rise of em- Policy, and 24 (1999): 489–530. 29. The cases demanding hospital prof/pubs/daily/0208/0826us.html. ployer health benefits, see Marie 21. Derickson, “Health Care for All?” compliance with federal uncompensated Accessed October 22, 2002. Gottschalk, “The Elusive Goal of Univer- 13 43; Theda Skocpol, Boomerang: care requirements had limited success, sal Health Care in the US: Organized 3. Ronald Numbers, Almost Persuaded: Health Care Reform and the Turn Against most notably with Cook v Ochsner (61 Labor and the Institutional Straightjacket American Physicians and Compulsory Government (New York: W.W. Norton, FRD 354; 1972), but attempts to re- of the Private Welfare State,” Journal of Health Insurance, 1912–1920 (Balti- 19 97), 92. strict “hospital flight” failed; Smith, Policy History II, No. 4 (1999): 367– more: Johns Hopkins University Press, Health Care Divided, 16 8–183. On hos- 398; Jennifer Klein, “Managing Security: 22. Gordon, Dead on Arrival, 3–4, 1978); Beatrix Hoffman, The Wages of pital desegregation, see Smith, ibid, The Business of American , 432. On pluralism in health politics, Sickness: The Politics of Health Insurance chap 3 and 4, and Jill Quadagno, “Pro- 1910s–1960” (PhD diss, University of see, for example, Daniel Fox, “The De- in Progressive America (Chapel Hill: Uni- moting Civil Rights Through the Wel- Virginia, 1999); Raymond Munts, Bar- cline of Historicism: The Case of Com- versity of North Carolina Press, 2001), fare State: How Medicare Integrated gaining for Health: Labor Unions, Health pulsory Health Insurance in the United chap 4. Southern Hospitals,” Social Problems 47, Insurance, and Medical Care (Madison: States,” Bulletin of the History of Medi- No. 1 (2000): 68–89. 4. Hoffman, Wages of Sickness, chap University of Wisconsin Press, 1967). cine 57 (1983): 596–610. 7 and 8. On the Committee for National Health 23. Pauline Newman speech, American 30.“Visit to Syracuse Urban League

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Enrichment of Community Health Pro- folder 1, box 42 (the Ryan White tives but prefers to emphasize “univer- gram,” unknown author, Sept. 7, 1972, CARE Act, or Comprehensive AIDS Re- sal coverage” over “single-payer” to folder 6, box 67, Papers of the National sources Emergency Act, was eventually avoid alienating potential supporters; Urban League, Library of Congress. On funded, and reauthorized in 1996 and Corinne Sutter-Brown, communication community health programs, see Alice 2000); “Dear Comrade,” April 16, with the author, August 14, 2002. Sardell, The US Experiment in Social 19 91, folder 3, box 41; “A Call to Ac- 45. “2002 Annual Conference,” avail- Medicine: The Community Health Center tion,” April 1993, folder 7, box 50, able at: http://www.uhcan.org/files/ Program, 1965–86 (Pittsburgh, Pa: Uni- ACT UP-NY Papers. about/conference_2002.html, accessed versity of Pittsburgh Press, 1988). 39.Physicians for a National Health October 22, 2002. 31. Boston Women’s Health Book Col- Program, “The History and Accomplish- 46. See, for example, Jennifer N. Ed- lective, Our Bodies, Ourselves (New York: ments of PNHP,” no date, in the au- wards, Michael M. Doty, and Cathy Simon and Schuster, 1971), quoted in thor’s possession. On physicians’ reform Schoen, “The Erosion of Employer- Major Problems in the History of Ameri- organizations, see Engler, Doctors and Based Health Coverage and the Threat can Medicine and Public Health, ed. John Reformers; on the grassroots organizing to Workers’ Health Care,” Issue Brief Harley Warner and Janet Tighe (New of medical students, see Naomi Rogers, (Commonwealth Fund, New York, NY), York: Houghton Mifflin, 2001), 501– “‘Caution: The AMA May Be Danger- August 2002; “Elderly Worry as Insur- 504. ous to Your Health’: The Student Health ers Cut Medicare Plans for 50000,” Organizations (SHO) and American 32. Ann Shola Orloff, Julia S. O’Con- New York Times, December 26, 2000, Medicine, 1965–1970,” Radical History nor, and Sheila Shaver, States, Markets, B4; Robert Pear, “Many Doctors Shun Review 80 (spring 2001): 5–34. Families: Gender, and Social Patients With Medicare,” New York Policy in , , Great Britain 40.For an overview of state cam- Times, March 17, 2002, 1; Stephanie and the United States (New York: Cam- paigns, see “Health Care Justice in the Simon, “Medicaid Ax Is Falling as Re- bridge University Press, 1999), 182– States,” available at: http://www.uhcan. cession Saps States,” Los Angeles Times, 183. org/files/states/states.html, accessed Oc- March 5, 2002, A1. tober 22, 2002. 33. Jennifer A. Nelson, “‘Abortions 47. Nancy Tomes, “Merchants of Under Community Control’: Feminism, 41. Health Care for All Oregon, “Par- Health: Medicine and Consumer Cul- Nationalism, and the Politics of Repro- tial List of Measure 23 Supporters,” ture in the United States, 1900–1940,” duction Among New York City’s Young available at: http://www.healthcareforall Journal of American History 88 (2) Lords,” Journal of Women’s History 13 oregon.org/endorsers.htm, accessed Oc- (2001): 519–547. (spring 2001): 157–180. tober 22, 2002. The Oregon initiative 48. Quoted in Martin Kuz, “A Faint failed on November 5, 2002, just as 34. Anne S. Kasper, “Health Care Re- Pulse: Universal Health Care, a Concept this article was going to press. Oppo- form: A Women’s Issue,” July 2001, Left for Dead, Twitches Back to Life,” nents spent $1.4 million and ran a last- available at: http://www.ourbodiesour- Cleveland Scene, April 11, 2002. Gor- minute advertising blitz, supporters selves. org/reform.htm; Campaign for don is the founder of Ohio’s Single spent only $35000, and Oregon resi- Women’s Health, “A Model Benefits Payer Action Network. dents already faced a tax increase due Package for Women in Health Care Re- to state budget shortfalls. “Voters Reject form,” ca. 1992, in the author’s posses- Initiatives,” Wall Street Journal, Novem- sion (thanks to Anne Kasper for provid- ber 7, 2002, A5. ing me with this document); Karen Nussbaum, “Why US Women Need the 42. This strategy is particularly evident Clinton Health Reform Package Now,” in Maryland, where gaining the en- Albany (NY) Times-Union, June 1, 1994. dorsements of over 1600 organizations However, reproductive rights supporters has been a top priority of health reform were unhappy that the Clinton plan activists; Maryland Health Care for All, failed to specifically mention abortion “Who We Are,” available at: http:// coverage; Sharon Lerner and Janet healthcareforall.com/whoweare, ac- Freedman, MD, “Abortion and Health cessed October 22, 2002. Care Reform,” Journal of the American 43. “Summary of Proceedings, 2001 Medical Women’s Association 49 National UHCAN Conference,” available (1994): 144– 146. at: http:// www.uhcan.org/files/about/ 35. See, for example, Steven Epstein, confproc_2001.html, accessed October Impure Science: AIDS, Activism, and the 22, 2002; “Activists Denounce Anthem Politics of Knowledge (Berkeley: Univer- as ‘Villain,’” Portland Press Herald, June sity of California Press, 1998). 1, 2002. Opponents of the Portland ref- erendum spent $400000, backers 36. The records of the Insurance and $30000; “5 Firms Vie to Study Univer- Access Committee are in boxes 41-55, sal Health Care Feasibility,” Bangor ACT UP–NY Papers, New York Public Daily News, June 25, 2002. Library. 44. The Maryland Citizens’ Health 37.“People of Color AIDS Activist Initiative, while still in the policy devel- Conference,” ca. 1990, folder 3, box opment stage, will propose a mix of 41; “Comments of the Insurance and public and private insurance as a step Access Committee of ACT UP/NY,” toward universal coverage; see http:// February 11, 1991, folder 3, box 41; healthcareforall.com/theplan.htm, ac- Flyer, ca. 1991, folder 1, box 42, ACT cessed October 22, 2002. UHCAN, a UP–NY Papers. major umbrella group founded by Ohio 38. ACT UP Healthcare Campaign reformers and disability activists in Working Group, “Memo #1,” ca. 1990, 19 92, supports state single-payer initia-

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