When Congress created the Medicare health insurance program in 1965 and President Lyndon Johnson signed the landmark legislation – that’s LBJ handing one of his pens to Harry Truman who had long advocated for the program – the law gave the Johnson Administration less than a year to implement the vast new groundbreaking program. More than 19 million elderly Americans were immediately eligible for Medicare coverage in the summer of 1966 when the law went into effect, but there was widespread concern that the program wouldn’t work.
As Sarah Kliff wrote recently in the Washington Post “nobody knew whether the new program would provide benefits to millions or fail completely.”
“What will happen then, on that summer day when the federally insured system of paying hospital bills becomes reality?” Nona Brown, a New York Times reporter, wondered in a story published in April 1966. “Will there be lines of old folks at hospital doors, with no rooms to put them in, too few doctors and nurses and technicians to care for them?”
Many of the same questions are being asked now about the Obama Administration’s Affordable Care Act (ACA), particularly in light of the news dump in the middle of the July 4 holiday period that one of the most controversial portions of the law, the employer mandate, will be postponed for a year. Obama and those charged with implementing the ACA should hope they fare as well as those uncertain bureaucrats did back in 1966. By the time Medicare took effect 47 summers ago more than 93% of eligible seniors had enrolled, but it required an extraordinary effort to properly launch the program that was once labeled by the American Medical Association as the “beginning of socialized medicine.” Today, of course, politicians mess with Medicare at their peril – ask Paul Ryan – doctors most often now complain about reimbursement levels and the program that many once thought couldn’t be made to work is one of the most popular government programs ever.
How did LBJ and his administration pull it off? And are there lessons in that history of almost 50 years ago for those struggling to implement Obamacare amid predictions that a “train wreck” in coming?
One fundamental difference between 1966 and 2014 (when the ACA goes into effect) is the personality and style of the men occupying the Oval Office. Lyndon Johnson possessed an almost obsessive love of pulling the levers of presidential power. With his White House micro-managing almost everything the U.S. Forest Service actually sent its personnel out into the woods to find “hermits” and sign them up for Medicare. The government hired thousands of temporary workers, opened hundreds of new offices and literally sent people door-to-door campaign style to find eligible elderly folks. It helped that no one sued the Johnson Administration over the implementation of Medicare and that both the government and the country were smaller in 1966. It also didn’t hurt Medicare implementation that the White House and both houses of Congress were controlled by the party that had for a generation or more pushed for its passage. LBJ had no John Boehner to contend with.
Still with many doctors and hospitals skeptical of Medicare the Johnson Administration faced major hurdles in the implementation effort, including the obvious need to get providers suited up for the launch. Government workers enlisted the American Hospital Association to educate hospital administrators and, believe it or not, the television networks donated time to promote the program. Private insurers were contracted to serve as intermediaries with program participants. When Social Security Administrator Robert Ball briefed the Johnson Cabinet in May of 1966 he confidently predicted that there would be some rough spots, but that the implementation would come off on time and it did.
One issue Johnson’s bureaucrats had to contend with that thankfully doesn’t exist today was a provision in the Medicare act that required hospitals to be certified in advance as being in full compliance with the Civil Rights Act of 1964. In other words hospitals could not participate in the new program unless they supplied services equally to whites and blacks. Some southern hospitals held out for a time, but eventually came around when it became apparent that elderly whites as well as African-Americans were being denied coverage.
On July 25, 1966 the New York Times reported that “M-Day” had come and gone with civil rights compliance the only major problem. The fears of vast overcrowding of hospitals or that elderly would resist signing up and paying a $3 per month fee simply didn’t materialize.
Obama has his own sticky issues, including Senate Minority Leader Mitch McConnell threatening the heads of major professional sports leagues if they even think about helping spread the word on the ACA and the House of Representatives still voting regularly to repeal the law. Once Medicare passed LBJ had little overt opposition to contend with. In truth the Republican Party of the 1960’s was sharply split over Medicare. High profile conservative leaders like Barry Goldwater and Ronald Reagan warned against the evils of socialism, with Goldwater asking what was next after free health care for the elderly, “a ration of cigarettes for those who smoke and of beer for those who drink.”
Still four of the eight Republicans on the Senate Finance Committee supported the bill in committee in 1965. In the House 68 Republicans opposed the bill on final passage – including Representatives Bob Dole of Kansas and George H.W. Bush of Texas – but 70 House Republicans voted in favor. A sizable number of conservative Democrats, many from the south – the parties in those days actually had liberal and conservative wings – also opposed Medicare.
So will implementation of the Affordable Care Act crumble under the weight of the complexity of the law and the still fierce Republican opposition? Barack Obama certainly faces obstacles to implementing his signature accomplishment that Johnson didn’t, including a hectoring House Speaker and at least a minority of the country that remains deeply skeptical of the new law. And, as he has before, Obama may find that he has to step up, become more visible and employ his considerable oratorical skills to save the day and define what success and failure would look like.
After ceding almost all of the decision making about crafting the ACA to Congress the president has done a consistently awful job of communicating about the finished product leaving many Americans to ponder, or more likely not, the “eyes glazes over” complexity of the legislation. The naysayers have largely won the battle to define the ACA, just as LBJ refused to allow Goldwater and others to define Medicare as a “communist plot,” and they now seem ready to try to win the battle over its implementation. But wishing Obama were more like Johnson in his willingness to use the power of his position is a little like damning the cat for not being a dog. Yet, it is unmistakably true that forceful, engaged executive leadership is most needed when policy and politics get the most difficult. That is a lesson for the ages.
Let’s give the last word to former federal Budget Director Alice Rivlin who could give the communicator-in-chief a few lessons in discussing complexity and politics. Rivlin wrote at the Brookings Center’s website: “In the polarized politics of our time, the opponents of the ACA have attacked it both as a federal government power grab—described as “socialism” by people who have forgotten what socialism is—and as overly complicated. But if it really were a federal power grab it wouldn’t be so complicated. The complexity is created by our two traditions of relying on private markets whenever possible and preserving diversity at the state level. These traditions are part of our political DNA, and if we value them—and most of us do–we should not complain that they make governance complicated.”
A Democratic administration once implemented a groundbreaking new law amid much skepticism and against considerable opposition. Times have changed, but it should be possible again. We’ll see.