Will Medi­care and Med­i­caid pre­dict ACA’s fu­ture?

Modern Healthcare - - 50 MEDICARE AND MEDICAID THE NEXT HALF-CENTURY - By Har­ris Meyer

While politi­cians de­bate the fu­ture of Medi­care and Med­i­caid, few ques­tion that those pro­grams are here to stay. It’s easy to for­get how con­tro­ver­sial the idea of gov­ern­ment health­care pro­grams was for most of the 20th cen­tury, and how many decades it took to en­act the pro­grams.

Sup­port­ers of the Af­ford­able Care Act, which ar­rived in a more po­lar­ized era, hope it will even­tu­ally re­ceive sim­i­lar public ac­cep­tance. The his­tory of Medi­care and Med­i­caid of­fers some rea­sons to think the ACA will be­come a fix­ture of the health­care land­scape—and some to think it won’t.

Start­ing with Theodore Roo­sevelt in 1912, po­lit­i­cal pro­gres­sives, la­bor union ac­tivists and so­cial re­form­ers pushed for a na­tional health in­sur­ance sys­tem. But af­ter Pres­i­dent Harry Tru­man’s 1948 bid for a uni­ver­sal, sin­gle-payer plan failed be­cause of op­po­si­tion from con­ser­va­tives and or­ga­nized medicine, sup­port­ers fo­cused on ex­pand­ing cov­er­age for the el­derly. They hoped to build on those gains to ex­pand cov­er­age to the rest of the pop­u­la­tion—never dreaming that their quest would con­tinue well into the 21st cen­tury.

For Medi­care pro­po­nents, start­ing with cov­er­age for the el­derly seemed like smart pol­i­tics. “Ev­ery­one has par­ents,” noted Dr. David Blu­men­thal, pres­i­dent of the Com­mon­wealth Fund, who has writ­ten about the his­tory of Medi­care and Med­i­caid. Se­niors are widely seen as a “morally wor­thy” pop­u­la­tion, said Theda Skocpol, a Har­vard Uni­ver­sity gov­ern­ment pro­fes­sor who has writ­ten about health­care re­form.

In­sur­ing the poor was an af­ter­thought for Pres­i­dent Lyn­don John­son, who fo­cused on cre­at­ing Medi­care fol­low­ing the Democrats’ land­slide elec­tion victory in 1964. In­deed, Rep. Wil­bur Mills (D-Ark.), the House Ways & Means chair­man who led the bill’s draft­ing, in­cluded Med­i­caid cov­er­age for the poor at least partly as a way to blunt fu­ture pres­sure to ex­pand cov­er­age to ev­ery­one, which he op­posed. When John­son signed the Medi­care and Med­i­caid leg­is­la­tion on July 30, 1965, he did not men­tion Med­i­caid by name, noted Theodore Mar­mor, a Yale Uni­ver­sity pro­fes­sor emer­i­tus of public pol­icy.

The po­lit­i­cal cir­cum­stances sur­round­ing pas­sage of the law and the ACA have many similarities. In both cases, a Demo­cratic pres­i­den­tial can­di­date had cam­paigned on ex­pand­ing health­care and won a big elec­tion victory. Each then moved quickly to pass a re­form plan. Con­gres­sional lead­ers also played strong roles.

Both Pres­i­dent John­son and Pres­i­dent Barack Obama learned from their pre­de­ces­sors’ failed health­care re­form at­tempts. Lib­er­als made ma­jor com­pro­mises to win pas­sage. Both ef­forts avoided strict cost con­trols to avoid stir­ring up health­care in­dus­try op­po­si­tion.

But there also were im­por­tant dif­fer­ences. Un­like the ACA’s cov­er­age ex­pan­sions, there was some GOP sup­port in 1965 for ex­tend­ing cov­er­age to se­niors and the poor. Medi­care built on the im­mensely popular So­cial Se­cu­rity pro­gram, and was avail­able to ev­ery­one re­gard­less of in­come.

In 1965, there was still broad public sup­port for gov­ern­ment so­cial pro­grams. La­bor unions were far more pow­er­ful than they are to­day. By 2009, op­po­si­tion to gov­ern­ment health­care pro­grams had be­come much more cen­tral to the GOP, which had grown more ide­o­log­i­cally con­ser­va­tive, Skocpol said.

For mod­ern-day Repub­li­cans, the suc­cess of gov­ern­ment-led health­care re­form threat­ens to un­der­mine their core po­lit­i­cal mes­sage. In 1993, GOP strate­gist Wil­liam Kris­tol fa­mously warned that if Pres­i­dent Bill Clin­ton won pas­sage of his health­care re­form leg­is­la­tion, “its suc­cess would sig­nal a re­birth of cen­tral­ized wel­fare-state pol­icy … and strike a pun­ish­ing blow against Repub­li­can claims to de­fend the mid­dle class by re­strain­ing gov­ern­ment.”

“Repub­li­cans un­der­stand the long-term po­lit­i­cal stakes bet­ter than Democrats,” Skocpol said. “That’s why they have fought the ACA tooth and nail.”

One les­son Obama and fel­low Democrats failed to learn from John­son was the im­por­tance of get­ting the pro­gram off to a strong, fast start. That Oba­macare weak­ness gave op­po­nents ammunition Medi­care’s foes never had. Medi­care en­rolled nearly all se­niors within a year of the pro­gram’s cre­ation and quickly be­came popular. In con­trast, it was four years be­fore the ACA’s cov­er­age ex­pan­sion took full ef­fect, and the launch was rocky.

Nev­er­the­less, ob­servers agree that it’s hard to take back gov­ern­ment benefits that mil­lions of Amer­i­cans have come to ap­pre­ci­ate and that also help pow­er­ful health­care in­dus­try groups. That’s what ACA sup­port­ers are count­ing on to give the law the same stay­ing power as Medi­care and Med­i­caid. “Congress doesn’t take things away from peo­ple,” Blu­men­thal said.

To­gether with the cov­er­age gains made pos­si­ble by the Af­ford­able Care Act, Medi­care and Med­i­caid pro­vide a struc­ture that does so much to pro­tect hu­man dig­nity and im­prove the health of all our com­mu­ni­ties.


The two pro­grams rep­re­sent the largest step to­ward com­pas­sion and so­cial jus­tice in Amer­i­can public pol­icy in th­ese cond half of the 20th cen­tury, and they’ve in­creased trans­parency and ac­count abil­ity in the health care sys­tem.



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