Like many, I have been moved by the touching concern of Republican leaders for preserving Medicare. They fret that unless we do something, Medicare will vanish, and when that happens, it will be a very, very bad day. Such heart-felt sentiment always brings to mind Ronald Reagan’s maxim, “Trust but verify.”
Medicare was signed into law on July 30, 1965 by President Lyndon Johnson at a ceremony in Independence, Missouri. He was in the Show-Me State to give President Harry Truman the first Medicare card.
How had we gotten to that point? Howard Dean was incorrect when he suggested that Medicare was passed without the help of Republicans. In fact, of the 32 Republicans in the Senate 13 voted “aye” and 17 “nay.” While Senate Minority Leader Everett Dirksen did not vote, he went on record in saying that he would have voted in favor. In the House, the Republicans were almost precisely split. Medicare demonstrated the division in the party prior to the Southern realignment. (In the Congress Democrats were more united, but seven Senators and 48 Representatives voted no).
But what was striking was the fact that the arguments against the creation of Medicare by its opponents were similar to those aimed at what some have termed “Obamacare” (I know it has a less snippy label – the Patient Protection and Affordable Care Act – but recognize its maker). I acknowledge Ira Rosofsky’s 2009 essay, “Medicare is Socialism” on his blog “Adventures in Old Age,” for capturing some pithy examples, which I have supplemented.
The leading opponent of Medicare as it passed was the American Medical Association, a professional association that, generally speaking, supports our recently enacted health care law. Had they been opposed, the outcome might have been very different. (Whether they were bought off or whether the economic and organizational structure of medicine has changed, I leave for others. I whisper both). In June 1965, the AMA fired their cannons, describing Medicare as “the beginning of socialized medicine.” They urged their members to boycott Medicare. Others worried that Medicare, a government insurance plan, would drive private plans out of business. Lyndon Johnson was linked to Norman Thomas, the standard bearer of the Socialist Party. Others spoke of the enforcement of “coercive collectivism” and the creation of “serf doctors.” One can almost hear distant tweets from Wasilla.
Ronald Reagan released a phonograph record in opposition to “socialized medicine.” He trusted that if the law were to be passed, “one of these days we are going to spend our sunset years telling our children and our children’s children, what it was like in America when men were free.” With our extended life expectancy, in part a result of Medicare, we can now tell our children’s children’s children. Barry Goldwater remarked, “Having given our pensioners their medical care in kind, why not food baskets, why not public housing accommodations, why not vacation resorts, why not a ration of cigarettes for those who smoke.” Well, forget the cigarettes; times change.
And perhaps the critics were not so fuzzy-headed. Medicare is a form of government-supported medicine, an imperfect, incomplete single-payer system. Our aging population is, in part, a success of the very program that the success is threatening. Medicare has significant challenges both on cost and revenue sides.
But what is striking is that Republicans speak in unison that they do not wish to eliminate federal subsidies for health care for the elderly. There is a wide consensus that government support for health care for senior citizens is right and proper. It may well be that if Paul Ryan’s plan to replace direct payments to physicians with subsidies for insurance will fundamentally change the face of Medicare, but even Republicans are not proposing repeal of this form of income redistribution. Even – gosh and golly – Ron Paul expresses his support for this non-libertarian approach to state-sponsored financial transfer. I might be wrong – and perhaps insufficiently skeptical – but I believe that they are sincere. Republicans have accepted Medicare, just as they have embraced Social Security. Yes, there are fundamental and crucial distinctions in how liberals and conservatives would transfer wealth, but there is no call for every geezer for herself.
If my estimation is correct, this is how it should be. Conservatives – at least of the Burkean stripe – will come to terms with ideas that prove their mettle, even if changes are enacted over their opposition. This is not hypocrisy, but the wisdom of time. The wide approval of Social Security among Republicans is a case in point. It was the inability of President Bush to gain significant Republican support that sunk his (modest) plan to privatize a portion of Social Security. The Ryan proposal is running into headwinds as well, protected because it will not be enacted. Liberals tend to believe in the eternal validity of ideas, while conservatives are reluctant pragmatists after the fact. And this is why a political system that permits an oscillation of liberal hegemony, creating new programs, and conservative dominance, cementing and winnowing those ideas, is valuable.
If Medicare was socialism yesterday, it is Americanism today. Will we say the same about Obamacare in 2055?
Soon or later the politics of Social Security, Medicare and Medicaid will have to catch up with the actuarial calculations. Sooner or later, hopefully sooner, policy makers will have to address the imbalances between cash out for these programs and sources of cash for them. The actuaries have been aware of the problems for a long time, but for the most part, elected politicians have ignored them. Perhaps this is what is being played out now. If the Sarbanes-Oxley Act applied to public officials perhaps, the public statements by our elected politicians about these programs might be more in line with the actuarial projections and trustee reports which continue to point to the financial problems with these programs. “Everyone” may be aware of the problems pointed out by the actuaries and trustees, and we may have a modern policy case of the “emperor’s new clothes.” Perhaps we could learn something by re-reading the Hans Christian Andersen fairy tale. For decades, I’ve worked with and relied on the analyses provided by actuaries. It is all about the math. If we focused on the math and the new demographics, then perhaps progress could be made on policies to address Social Security, Medicare and Medicaid.
If both cuts to medicare or social security as well as tax increases, even closing tax loopholes, are off the table, then talk about cutting the budget deficit is both cheap (and expensive). As long as the public debate is informed as much by ideology as by actuarial projections (lets just call them “facts” in this case) the problem will not be solved. I would like to think that once the s#&t hits the fan, politicians will start to become more realistic, but I think it is just as likely that they will play the blame game and resort to opportunism. How bad do things need to get before it truly is “all about the math”?