This week marks the 48th anniversary of LBJ signing the Social Security Act of 1965 into law, creating Medicare and Medicaid. By current counts, there are 48 million Americans who use Medicare and 69 million who use Medicaid. That is a full one-third of the US population. And this is even before the ACA marketplaces come online. And just like the reforms being implemented over the course of the next few months and years, this act was not without contention. President Harry Truman had been the first to propose a national health insurance program in 1945, in the wake of soldiers returning after World War II. He called for “Health security for all; Regardless of residence, station, or race- everywhere in the United States.” Similar programs were being created across Europe and Japan, laying the groundwork for helping those countries achieve universal health care coverage by mid-century. Of course the work would be far more arduous in the US, with opposition from a number of corners, from fiscal conservatives to social conservatives who viewed it as creeping communism, to voices of the medical community, including the AMA. It took until 1965 in Johnson’s push for the Great Society that guaranteed national health insurance for the aged, and indigent, and later the disabled (in 1972). And the first to enroll in Medicare? President Truman, at age 81, present alongside LBJ at the signing of the bill. The deductible for Part A (covered hospital costs) was $40, and the monthly premium for Part B (outpatient costs) was $3.
Over 1 million Americans enrolled in the first week, with Social Security office staying open until late in the evening. This makes the goal of enrolling 7 million Americans in health exchanges, the great majority online, seem completely feasible in comparison. And the significance went far beyond just health care. Only racially integrated hospitals could be reimbursed under the program, so with this symbolic flourish of his pen, LBJ signed into law the effective end of segregated hospitals. By 1970, insurance coverage among those over 65 rose from less than half to 97%.
And just like the ACA- Medicare was a work-in-progress. And just like the ACA, revisions and improvements came with political horse-trading. A number of key votes wanted drug coverage to be included in the revision to the bill in 1972, and with opposition fearing cost would be prohibitive, a compromise was reached with extending coverage to patients with severe kidney disease, ending an effective death sentence due to limited carrying capacity of dialysis machines. This piece of technology had come to symbolize an overt, explicit form of rationing, forcing doctors and insurance companies to decide who had access, and who did not. In addition the 1972 bill extended coverage to those with severe disabilities.
In 1982, hospice benefits were included in Medicare- foreshadowing debates we still find ourselves mired in today. What were called “death panels” by opponents of health care reform, are really an addition to a focus on end-of-life care, reimbursing doctors for discussing with their patients their preferences with the inevitable comes to pass. As far back as 1983, reforms were enacted to try to control Medicare costs, moves which would be echoed again in 1997 which crafted a “Sustainable Growth Rate” formula, meant to help control how fasts costs could inflate. As we know, this is a challenge still facing the health care system as a whole, including now what exactly to do with that formula from 1997- instead of holding down costs, a patch has been put in place every year to make sure reimbursements are met.
From just this select list of challenges, without even mentioning the passage and repeal of a catastrophic coverage amendment with drug benefit in the late 1980’s, it becomes clear that one of the cornerstones of American social policy, and now one of the most untouchable from a political perspective, has had plenty of obstacles and detractors over the course of its 48 year history. And the ACA is just at the beginning of this road.
Both face the challenge of how to control costs in our health care system. $3 may sound like nothing, medical science and interventions were also a pale shadow of the near miracles we can perform now. This is not to say that all the increased investment is wisely spent, or that we don’t have important dialogues to undertake in determining what treatments are truly effective, and beyond that how to encourage healthy lifestyles in our culture at large. We still have vigorous debate about the balance between individual responsibility and social conditions, as well as the role of government versus private industry to help address these challenges. We likewise still face the reality of income inequality and socioeconomic disparities which impact the health of individuals disproportionately, making your zip code a startlingly good predictor of life expectancy, which can vary by a decade from nearby locales. But as we mark the 48th anniversary of the creation of Medicare, we are reminded that none of these challenges are new. And none are intractable. And as the ACA, or Obamacare rolls out, I can only speculate how LBJ would have felt if Medicare was down in the history books as Johnsoncare, but I can bet he, and all those working in this vein before and since, would have been proud.