Waiting for Another L. B. J.
IN March 1964, President Lyndon B. Johnson eyed one of the toughest unfinished tasks he had inherited from John F. Kennedy: creation of a national health care program for the elderly. With typical ambition and determination, he told his aide on health care, Wilbur Cohen, "We're going to spend the rest of our lives if necessary passing medical care."
Fifteen months later, on July 30, 1965, Johnson traveled to Independence, Mo., and with Harry Truman at his side, signed the legislation that created Medicare, whose 40th anniversary we celebrate today.
If Johnson were alive, he would view Medicare with both pride and anxiety: pride in enormous past accomplishments, anxiety about an uncertain future. He would also probably be scratching his balding head over the way Medicare exemplifies the American health care system's enduring contradictions: its huge costs and persistent gaps in coverage.
Medicare was born in strife. The legislation emerged from a titanic struggle that raged across the American political landscape starting in 1949, when Harry Truman first proposed national health insurance.
Conservatives saw Medicare as a potentially mortal intrusion of government on the American way of life. "We will awake to find that we have socialism," Ronald Reagan warned in 1962. The American Medical Association, one of the most feared lobbies of that time, tenaciously opposed Medicare. For their part, liberals saw Medicare as the first step toward long overdue federal health care coverage for all Americans.
In the end, Medicare's passage required a huge Democratic landslide in 1964, and a president who possessed not only energy and commitment, but also unparalleled legislative skills. Indeed, recently released tape recordings from the Johnson archives show the president functioning at times like a supermajority leader for both houses of Congress during the Medicare deliberations. After the bill passed the House Ways and Means Committee on March 23, 1965, Johnson spoke with Speaker John McCormack, instructing him with Texas earthiness to make haste: "Now don't you let that dead cat hang around." Even so, Medicare initially passed the House by only 45 votes.
Johnson would almost certainly feel today that the results were well worth the effort. Medicare - and its companion program, Medicaid, for the poor - made America a far more decent and healthy place, not only for the elderly but for younger generations who care for them. Before Medicare, only half of America's elderly had any kind of health insurance. But today, this country's 42 million elderly and disabled can visit virtually any doctor or hospital on any given day and receive the best care our health system has to offer. Older Americans now enjoy one of the highest average life expectancies in the world. That achievement is not all due to Medicare but hard to imagine without it.
Nevertheless, Johnson would most likely be concerned about a program that is entering middle age burdened by growing infirmities. Medicare provides insufficient coverage for long term care services that are increasingly vital to older Americans living longer with chronic illness. Drug coverage, only recently created under the Medicare Modernization Act of 2003, is still incomplete and complex. Because of these continuing gaps, elderly Americans actually pay more for health care as a percent of their income now than they did before Medicare was enacted: 21.7 percent in 2000, versus 19.1 percent in 1965. Paradoxically, the program is also extremely expensive and wasteful. With the addition of the new drug benefit, the Congressional Budget Office estimates, it is expected to cost nearly $773 billion by 2015.
In its perplexing costs and gaps, Medicare mirrors our health care system generally, whose expenses will soon exceed $2 trillion - more than the gross domestic product of Great Britain or France - yet leaves 45 million Americans uninsured. It will be hard to preserve Medicare's benefits without finding solutions to our broader systemic problems, because Medicare relies on that system to serve elderly Americans.
Medicare's history suggests that tough problems in health care can be solved, but only after long struggle, and only with visionary and effective leadership from the highest reaches of our political system. Johnson pulled out all the stops for Medicare. He told Vice President Hubert Humphrey on March 6, 1965: "I'll go a hundred million or a billon on health or education. I don't argue about that any more than I argue about Lady Bird buying flour." He added: "I may cut back some tanks. But not on health."
One measure of Johnson's achievement is surely that Republicans, who have gone from reviling Medicare to enacting its costly new drug benefit, have accepted the program as part of America's social safety net and political firmament. But Medicare's mixed history also suggests that, in health care at least, no solution is ever final. Preserving its benefits, and fixing our failing health care system, will require strong support from the American public and a president as committed and politically agile as Lyndon Baines Johnson. It would be tragic if we had to wait four more decades for this rare combination to emerge.
