Thoughts on Lyndon Johnson and Medicare and Medicaid

I was listening to NPR yesterday when on whatever show I was listening to they started talking about the past attempts by President's to reform health care.  What got me thinking in this conversation was when they brought up how Lyndon Johnson decided to be incremental and fight to establish Medicare and Medicaid.  Assuming the absence of universal coverage, few Americans, and no good lefty will deny the positive impact of Medicare and Medicaid on the American health care landscape.  Imagining America without those two programs is a sorry picture even considering the long term budgetary problems that Medicaid faces, including in Oregon with its innovative Oregon Health Plan.  That budgetary challenge is a function of rising health care costs in general and is a primary reason that health care reform is necessary, but I digress, imagining America without those two programs is a sorry picture of deep poverty and very high rates of uninsured.

The question, however, is whether that situation would be so intolerable as to provide the extra momentum for Johnson, Nixon, Carter, or Clinton to pass universal health care.  My sense is that Johnson pushed through an agenda that helped a lot of people, but at the cost of a long term fix to America's health care crisis.  He created a sense of complacency, and shockingly in the recent debate, selfishness.

The biggest barrier to momentum on health care reform during the current debate (other than institutional barriers in the Senate) has been the hostility of elderly Americans who, however incorrectly, think that Democrats are trying to kill them, or cut their medicare.  The Survey USA poll cited at the top of this paragraph finds Americans over the age of 65 to be the only group in which a plurality opposed the Obama outline plan.  Now, lets pretend that Medicare didn't exist, and elderly Americans are struggling to get health care coverage.  Not only do elderly Americans without health insurance become strong supporters of universal health care, but it also builds support for the program amongst younger Americans who are tired of watching their grandparents suffer.

The moral of the story is this, while Johnson eased a lot of suffering and passed two very good programs by fighting for Medicare and Medicaid, he simultaneously took the wind out of the sails for universal health care, and made the moral case for health care reform more dubious by allowing opponents to frame the uninsured in negative terms to a greater extent than they otherwise would be able to.  Half measures do not work, they are unable to bring the costs down, and improve the position of opponents of reform in future battles.  Johnson was able to pass both Medicare and Medicaid by big margins, had he decided to fight that battle I can't imagine with most elderly Americans lacking health insurance, plus those who gained coverage through medicaid, plus everyone that was left out by the Great Society Health Care reforms all pressuring the Senate and House, that we would not have managed to pass some version of universal health care, quite possibly in a better form than Obama's proposal.  I recognize that the House and Senate are not necessarily a reflection of public opinion, but the 120 million Americans (do not put too much stock in this number, I just added the uninsured, plus 1/2 of the elderly, plus medicaid enrollment, I actually suspect that due to the economics of the matter the number would be higher, either way it wasn't a particularly scientific approach that got me there) who would be uninsured today if Medicare and Medicaid didn't exist would not be such a ho-hum affair, and it would be a lot harder for opponents to stand in opposition.  The moment to do this was 1965 and Johnson blew his chance and made it a lot harder to pass universal health care.  At the same time, he made a lot of people's lives better and reshaped America rather than fighting a battle that he wasn't sure if he could win.