The government’s role in health care at both the state and federal level began gradually. Wars, economic instability, and political differences between parties all shaped the government’s role. The first major federal governmental action relating to health was the creation in 1798 of the Public Health Service (PHS). Then in 1890 federal laws were passed to promote the public health of merchant seaman and Native Americans. In 1934 Senator Wagner of New York initiated the first national health insurance bill. The Social Security Act of 1935 was passed to provide assistance to older adults and the unemployed, and it offered survivors’ insurance for widows and children. It also provided for child welfare, health department grants, and maternal and child health projects. In 1948 Congress created the National Institutes of Health (NIH), and in 1965 it passed very important health legislation—creating Medicare and Medicaid to provide health care service payments for older adults, the disabled, and the categorically poor. These legislative acts by Congress created programs that were implemented by the executive branch. In March 2010, the most recent legislation passed and signed by President Obama to improve the health of the nation and access to care was the health reform law, the Patient Protection and Affordable Care Act (US LAW, PL 111-148). The legislation was designed to do the following:

The U.S. Department of Health and Human Services (USDHHS) (known first as the Department of Health, Education, and Welfare [DHEW]) was created in 1953. The Health Care Financing Administration (HCFA) was created in 1977 as the key agency within the USDHHS to provide direction for Medicare and Medicaid. In 2002 HCFA was renamed the Center for Medicare and Medicaid Services (CMS). During the 1980s, a major effort of the Reagan administration was to shift federal government activities, including federal programs for health care, to the states. The process of shifting the responsibility for planning, delivering, and financing programs from the federal level to the states is called devolution. Throughout the 1980s and 1990s, Congress has increasingly funded health programs by giving block grants to the states. Devolution processes including block granting should alert professional nurses that state and local policy has grown in importance to the health care arena. With the new health reform law, stimulus grants are being provided to state and local areas to improve health care access (HRSA, 2010).

The role of government in health care is shaped both by the needs and demands of its citizens and by the citizens’ beliefs and values about personal responsibility and self-sufficiency. These beliefs and values often clash with society’s sense of responsibility and need for equality for all citizens. A federal example of this ideological debate occurred in the 1990s over health care reform. The Democratic agenda called for a health care system that was universally accessible, with a focus on primary care and prevention. The Republican agenda supported more modest changes within the medical model of the delivery system. This agenda also supported reducing the federal government’s role in health care delivery through cuts in Medicare and Medicaid benefits. The Democrats proposed the Health Security Act of 1993, which failed to gain Congress’s approval. In an effort to make some incremental health care changes, both the Democrats and the Republicans in Congress passed two new laws. The Health Insurance Portability and Accountability Act (HIPAA) allows working persons to keep their employee group health insurance for up to 16 months after they leave a job (U.S. Law 107-105, 1996). The State Child Health Improvement Act (SCHIP) of 1997 provides insurance for children and families who cannot otherwise afford health insurance (U.S. Law, 1997).

With the new health care reform debates, numerous debates occurred in the House of Representatives and the Senate until there was agreement that the Senate version of the bill would be passed. On March 30, 2010 President Obama signed into law the Health Care and Education Reconciliation Act of 2010, which made some changes to the comprehensive health reform law and included House amendments to the new law (Kaiser, 2010a).

This discussion has focused primarily on trends in and shifts between different levels of government. An additional aspect of governmental action is the relationship between government and individuals. Freedom of individuals must be balanced with governmental powers. After the terrorist attacks on the United States in September (World Trade Center attack) and October (anthrax outbreak) of 2001, much government activity was being conducted in the name of protecting the safety of U.S. citizens.

It is interesting to note that before September 11, 2001, the congress and President, recognizing that the public health system infrastructure needed help, passed a law in 2000: “The Public Health Threats and Emergencies Act” (PL 106-505). This was the “first federal law to comprehensively address the public health system’s preparedness for bioterrorism and other infectious disease outbreaks” (Frist, 2002, p 120). This legislation is said to have signaled the beginning of renewed interest in public health as the protector for entire communities. In June 2002 the Public Health Security and Bioterrorism Preparedness and Response Act was signed into law (PL 107-188) in December 2002, with $3 billion appropriated by Congress, to implement the following antibioterrorism activities:

Yet it remains unclear just how much governmental intervention is necessary and effective and how much will be tolerated by citizens. For example, in 2010 approximately 49% of citizens were against the new health care reform acts, and the Republicans were seen as being obstructionists. A bill was also introduced into the House of Representatives to form a citizens’ alliance for health care reform. From this example, it shows how unclear government actions are when looking at citizen reactions (The Citizens’ Alliance, 2010).