Between 1883 and 1920 many European countries introduced government health insurance through social insurance arrangements or state-promoted expansions of existing voluntary mutual-aid arrangements. Progressive reformers in the US interpreted state-provided health insurance as the necessary and inevitable response to the moral and economic inadequacies of voluntary insurance and self-help arrangements for protecting households against the consequences of sickness. Given the developments in Europe and the introduction of Workers’ Compensation in many states before World War 1, the reformers believed that government health insurance was the next step in social progress for the US. At the initiative of the American Association for Labour Legislation (AALL) between 1915 and 1920, as many as eighteen US states investigated but rejected compulsory state health insurance (CHI). The AALL reformers and many scholars today consider this outcome to be a policy failure, one that is significant for explaining why there has been, and continues to be, so much opposition to the introduction of national health insurance in the US.

If CHI was efficiency enhancing and stood to make some or all wage-workers better off, as the AALL reformers argued, why then were legislators and political ‘brokers’ unable to evoke the necessary political action for its introduction? Anderson argues that the indifference of Americans towards compulsory health insurance in this early period left organized groups, such as doctors and life insurers with political clout and vested interests in the defeat of CHI, to determine the outcome.