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.

There's got to be an ad in this somewhere

The conservative strategy in opposing health care reform is clearly to scare the living crap out of the elderly.  The irony in all this being that it is Republicans who are the longstanding enemies of Medicare and social security.  As recently as the past election the Republican Nominee for President advocated cuts in Medicare to slash the federal budget deficit.  So it is really strange to see the Republicans turning seniors into their base as they oppose a centrist plan to reform health care.  So why hasn't Moveon or someone run an ad based on this quote:

"The reality of it is, this single-payer program known as Medicare is a very good example of what we should not have happen with all of our health care," said Steele. "The reality of it is, how many times have we been at the trough of bankruptcy and no money for the Medicare program, where Congress is running around like chickens with their head cut off, trying to figure out how to fix a program that they've already mismanaged? So now you want to do that, Congressman, on a larger scale? You want to include all of us. You're talking about taking our senior population, and expanding it to all of the population? Government cannot run a health care system. they've already shown that. Trust the private markets to do it the right way."

or this one.

We've had Medicare since 1965, and Medicare has never done anything to make people more healthy. If there's any opportunity for more healthy activity, it's going to be, again, a private, competitive...

There's got to be a way to counter the fear mongering, seems to me that while the Republicans are pretending that the Democrats are trying to kill Medicare we should be reminding them who passed and still supports Medicare and who opposed and still hates it.  Where are the moveon ads on this?

Patience My Friends

The health care debate seems to have picked up steam since Ron Wyden introduced a plan for universal health care a few weeks ago. Today, Paul Krugman wayed in on what needs to be done in the short term.

Universal health care, much as we need it, won't happen until there's a change of management in the White House. In the meantime, however, Congress can take an important step toward making our health care system less wasteful, by fixing the Medicare Middleman Multiplication Act of 2003.
...
What should Congress do? The new Democratic majority is poised to reduce drug prices by allowing -- and, probably, requiring -- Medicare to negotiate prices on behalf of the private drug plans. But it should go further, and force Medicare to offer direct drug coverage that competes on a financially fair basis with the private plans. And it should end the subsidy to Medicare Advantage, forcing H.M.O.'s to engage in fair competition with traditional Medicare.

Conservatives will fight fiercely against these moves. They say they believe in competition -- but they're against competition that might show the public sector doing a better job than the private sector. Progressives should support these moves for the same reason. Ending the subsidies to middlemen, in addition to saving a lot of money, would point the way to broader health care reform.

It seems to me that the calls for a national single payer health care program have been getting much louder the last few weeks, which is good. I agree with Krugman however, and have articulated this before (though perhaps not on this blog). In terms of necessity the time for this is absolutely now, today in a perfect world we should institute national health insurance. However, the institutional standing of our country at this moment does not lend itself to this possibility. Before we can institute such a program, Democrats absolutely have to control the executive branch. If we push too hard, too fast for national health insurance without controlling the executive branch we risk losing the argument at a time when there was never any possibility of passage. Bush cannot hold the veto pen when we pass such a program. That's why I believe Krugman is correct here, ultimately we need national health insurance, but in the meantime we cannot possibly get it signed into law today, so we should chip arround the edges of American health care to make some good positive changes for people that we can get passed into law.