A Government’s Failure to Communicate
Blog Housekeeping December 2008

A Healthcare History Lesson for Obama

[EDITORIAL NOTE: Pulitzer Prize-winning journalist Saul Friedman writes the bi-monthly Reflections column for Time Goes By in which he comments on news, politics and social issues from his perspective as one of the younger members of the greatest generation. He also publishes a weekly column, Gray Matters, on aging for Newsday.

Category_bug_reflections I’m old enough to remember how it was before Medicare. My mother-in-law was in declining health and my wife and I were seeing to her care. On one visit to her family doctor, a golfer whom we called Buzzie, he told us, “Boy, if she only had the money we could give her the treatment she should have.” We left him for a nice, non-Jewish doctor I had met on the police beat.

Yet honestly, even as a journalist in Texas, I was too young, callow and full of myself to follow the Medicare battles in the Congress or appreciate its importance when it became law in July 1965. Since then, I have used thousands of dollars of Medicare’s money. I’ve written endlessly about Medicare in my day job, and I consider myself an expert.

But only recently have I been reminded how Lyndon Johnson prodded conservative lawmakers to give millions of older, disabled and poorer citizens the nation’s first universal national health care insurance, Medicare and Medicaid.

Now, Johnson’s victory could and should serve as a lesson for Barack Obama if, as he has promised, he intends to strengthen Medicare and eventually provide universal health coverage for the rest of America. If he doesn’t pay attention to this past, his efforts may meet the fate of the Clintons’ health care proposal in 1993.

The model for Obama and his White House is contained in a fine, straightforward essay appropriately entitled, The Lessons of Success – Revisiting the Medicare Story, in the November 27, New England Journal of Medicine. The authors, David Blumenthal, an MD (an unpaid Obama adviser) and James Morone, note that

“…this was the only time in our country’s history when the federal government extended health care coverage to a vast new swath of the American public.”

Partisans may claim that George Bush’s Part D drug coverage in 2003 was also a huge and expensive expansion of Medicare, but that bill was passed by a Republican Congress in the middle of the night along party lines, and further privatized Medicare, taking government out of the program.

If anything, it weakened traditional Medicare. One of Obama’s early challenges will be to roll back the 12 years of Republican efforts, like Medicare Advantage, that sought to nibble Medicare to death. (I’ll be writing more about this issue in coming months).

Following John Kennedy’s murder and the overwhelming defeat of Barry Goldwater in 1964, Johnson had huge Democratic majorities in the Congress. Still, he faced the problems of the percolating Vietnam War and the civil rights struggles. And conservative Southern Democrats who were hostile to government programs ran many of the key committees. But as the NEJM essay points out, Johnson masterfully won the support of Ways and Means Chairman Wilbur Mills, by letting him take credit for the legislation. Indeed Mills surprised Johnson by adding what became Medicaid to the bill to cover the poor.

At the time, LBJ and his Great Society programs enjoyed great popular support, but that faded quickly. Thus one of NEJM lessons for President Obama: Act quickly, decisively, with a deep personal commitment to health care reform and an understanding of what you want in the legislation.

“Bill Clinton waited for nine months to introduce his Health Security Act in 1993, which allowed the opposition to mobilize and defeat him.”

In addition, says the essay, Obama needs to keep his health care proposal relatively simple and easy for the public to understand. Clinton’s attempt to assuage all the special interests - doctors, the insurance industry and the drug makers - ended up satisfying no one and confusing members of Congress.

Even now, Obama’s proposals are complicated and rely on the insurance industry for coverage, for he has rejected the single-payer idea and Medicare for all.

Finally, Johnson decided early on in his battle for Medicare to worry about cost later, much later. As the essay concludes,

“Major expansions of health care coverage rarely fit the budget.”
But the passage of Medicare was one of his great rewards, Johnson, said as he signed the bill sitting next to another great champion of national health insurance, Harry Truman. That’s company waiting for Obama to join.

[At The Elder Storytelling Place today, Florence Millo recalls how she learned about intricacies of Quilting - sewing and social.]


I am sorry to say that I paid absolutely no attention to all of that when it was happening, but I was a young newlywed in 1964 and had other thoughts on my mind. In my present circumstances, I thank profusely anyone who had anything to do with passage of Medicare!!

I look forward to reading your take on the hierarchical condition coding scam that puts all of the risk on the government leaving the health plans with nothing but gravy. The spiraling "cost" of Medicare is almost entirely about these financial management companies capitalizing with health care dollars.

I have had health insurance since it started, and Medicare is by far the best for me, the consumer. I agree with everything Mr Friedman says, and I intend to write to President Elect Obama and my congress people to say that single payer is the only sensible way to go. My husband, who has been a pretty conservative fellow most of his life agrees with me.

My Mom's final hospital stay was over 350K -- and that was just Medicare's payments. She also had private insurance thanks to my Dad's long service at Motorola before he died, I think that part was another 100K. Seeing those bills was what changed my mind about our need for national health care in this country. Without Medicare, there would have been nothing left of her estate to provide for my disabled sister and nephew's trusts for them to live on.

I hope we will all soon be able to benefit from some form of national universal healthcare. We truly can't afford NOT to provide it anymore.

And to those who say they don't want to pay for other people's care -- you already are. Those high bills your insurance pay are covering the costs of the uninsured, one way or another.

My husband just became eligible for Medicare last year. I accompanied him to the Social Security office to sign up.

I swear to you that every second we were there, I was terrified that something would go wrong, and Medicare would somehow turn into the nightmare world of private health insurance (which, being younger, is what I have).

Yet miraculously Medicare never asked about pre-existing conditions, childhood illnesses, weight, height, credit rating, employability, driving record, current prescriptions, or any of the other nasty intrusions of the so-called "free" market in health care. I was speechless with relief when he easily got the coverage that we'd believed for 30 years would one day be there. And it was.

Reform--big, bold, and total--to private insurance (including Medicare "Advantage" and "Part D" bailouts for the greedy insurance industry) can't come soon enough for me.

Would a simple scenario be:

Everyone has accessibility to universal medical care.

Insurance costs are shared by persons and employers equally.

Children are for free (e.g. under a parent's policy).

Unemployed or debilitated people's policies paid by state agencies.

Anyone who chooses can opt out of universal medical system and pay for private medical insurance (but, once they opt out not able to come back in).

Five points, that's it. I'd be interested to know why it has to be more complicated than that. These five points have been practiced for half a century in most European countries, more or less successfully. Why go about reinventing the wheel?

I say God Bless America - each month when I receive my Social Security check. I know what it is like to pay for health insurance privately and it "broke us". My husband and I only have Medicare and Drug Coverage and know that this Country needs to have an organized sensibly maintained health insurance for everyone - from womb to tomb. There should be options in place for those who don't want it and to simplfy it for our CITIZENS.

Medicare allows people to die in peace. My father told me that my mother's final illness would have been a financial catastrophe were it not for Medicare. As it happened, she was able to go with her faith and dignity intact. I don't know that that could have happened without Medicare.

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