Thursday, January 3, 2013

Legislative passage of Medicare

"Don't let dead cats stand on your porch." This famous quotation, attributed to President Lyndon Johnson during his strenuous and ultimately successful efforts to pass the 1965 bills that established the Medicare and Medicaid programs, embodied his approach to arguably the most important U.S. health care legislation until the 2010 Affordable Care Act. Translated, it meant that the best strategy for passing health care (and other potentially controversial) legislation was to act quickly and move bills along in the Congressional process before political opponents or outside advocacy groups had time to organize themselves.

The legislative passage of Medicare was the subject of the first of a series of monthly one-hour health policy seminars for Family Medicine fellows and residents at Georgetown University School of Medicine. The goal of this monthly series is for participants to gain a better understanding of the policy process at the federal, state, and local levels by reading and discussing real-life examples in a small group. These seminars will be led by me and the current Robert L. Phillips, Jr. Health Policy Fellow as well as selected guest faculty. Participants complete one or two short readings prior to the seminar (this inaugural session's assignment was "The Secret History of Medicare" from David Blumenthal and James Morone's The Heart of Power, pictured above).

Remarkably, Medicare was fully implemented only 11 months after the bill's signing, overcoming obstacles such as hospital segregation in the South, resistance from physician organizations such as the American Medical Association, and the logistical issues involved in issuing insurance cards to 18 million eligible seniors. As Medicare approaches its 50th anniversary, it faces huge budgetary challenges driven by increasing costs of health care and the demographics of the enormous "Baby Boom" generation, the first member of whom became eligible for Medicare benefits in 2011. This short video produced by the Kaiser Family Foundation summarizes changes that occurred in the program in the intervening years.

Liberal legislators saw Medicare as the first step toward enacting federally-administered universal health insurance for all Americans, while others saw it as a program, like health programs for active-duty military, veterans, and Native Americans, whose benefits were appropriately limited to specific groups and therefore must be defended against encroachment by future wide-ranging health reforms. Princeton professor Paul Starr has called this resistance to change by protected groups the "policy trap" that contributed to the defeat of the Clinton health reform proposal in 1994 and the near-defeat of the Affordable Care Act 16 years later.

Other points raised during today's seminar included the book's observation that "an honest economic forecast would have very likely sunk Medicare." Like every federally financed health insurance initiative to come, Medicare ended up costing substantially more than initially projected. (In fact, the reason that most provisions of the ACA, passed in 2010, don't take effect until 2014 was to allow the Congressional Budget Office - which didn't exist in 1965 - to artificially score it as deficit-reducing over a 10-year time period.) Ethical or not, Lyndon Johnson's decision to "lowball" the estimated costs of Medicare was essential to getting it through Congress.

Was President Johnson - the last President to previously hold the position of Senate Majority Leader - a political anomaly, or can lessons from his deft management of the Congressional process be applied to national health care policy today? What do you think about Blumenthal and Marone's lessons for future Presidents, listed below?

1. Presidents must be deeply committed to health reforms.
2. Speed is essential. Waiting makes reforms a lot harder to win.
3. Presidents should concentrate on creating political momentum.
4. Presidents must actively manage the Congressional process.
5. Know when to compromise and know when to push.
6. Pass the credit.
7. Muzzle your economists. First expansion, then cost control.

-  Kenny Lin, MD
   Director, Robert L. Phillips, Jr. Health Policy Fellowship
   Department of Family Medicine
   Georgetown University School of Medicine


  1. Really enjoyed the inaugural seminar this morning. President Johnson certainly showed impressive skill and savvy in pushing through so many significant pieces of legislation, including Medicare. Knowing when to compromise and when to push seems like a key for most of us, not just the President. An awareness of the social climate and political stream are important factors in advancing policy in any direction.

    I am not sure that "muzzling your economists" would be a popular position at this current time, I understand and support the concept of doing what is right and figuring out the financial piece down the road.

  2. Thanks for the book tip! I received it as a Christmas gift and am eager to crack into it.

    Despite the attempt of the ACA to make national health reforms it is interesting to me (in contrast LBJ's efforts) how mosaicized the implementation landscape will be. In talking about desegrating southern hospitals and implementing broad change in the 1960's, many aspects of the ACA will occur in states or regions such as Innovation Center pilots(e.g., ACOs) or state level (non)adoption of Health Insurance Exchanges (HIEs). Even in the greater DC area, MD is very keen to adopt all parts of the ACA on or ahead of schedule while it appears VA will let the federal government build its HIE. This will create different "laboratories of experimentation" which may yield interesting comparative results but allow disparities to persist in some regions of the country (an outcome somewhat diametric to Medicare passage). Of course many pieces of the ACA are national (insurnace reforms, coverage mandates, etc.) but again, unlike Medicare, there is little initial market consolidation of payer forces which may contribute to ongoing disparities in access to care.

    Thanks Dr. Lin for getting this post up and running!