When was medicare and medicaid enacted

The basic provision was originally included in the Forand bills, in and section d 5 , made more specific and enlarged by the legal staff of the Department of Health, Education, and Welfare when President Kennedy's Administration bill was introduced by Representative Cecil King D. No effort has been made, as far as I know, to amend or repeal this general provision. The basic pressure for a Medicaid-type program began to develop in when Rhode Island wanted to utilize some of the existing public assistance funds under the Social Security Act for direct payments to vendors of medical care.

Congress, It was too broad a proposal. When it seemed like no provision for medical assistance to needy persons would be included in the bill, I asked Elizabeth Wickenden, a long-time friend of mine in New York City, to remind Representative Walter Lynch D. With Representative Lynch's help, I was able to develop such an amendment, which was adopted by the Committee and the Congress and incorporated into the Social Security Amendments Public Law Thus, in a miniscule manner, the Federal role in financing medical care for the poor began.

In , with the inauguration of President Dwight D. This proposal failed to be enacted. This proposal was rejected on cost grounds by the Bureau of the Budget.

Then, in , Robert P. Flemming, urged President Eisenhower to endorse a Medicare-type plan financed through the social security system. When the bill came to the Senate, in the summer of , Senator Kerr requested me to review it and propose any changes to him within a few days.

They became known as the Kerr-Mills bill Mitchell, All during the years , I took the position that both Medicare-type and Medicaid-type programs were necessary and desirable and were not in conflict with each other. Mills readily accepted this view. The only other strong Medicare supporter I was able to persuade to take this view was my longtime friend, Senator Paul Douglas D.

Senator McNamara and his staff were critical of my views and my strategy Perrin, Senator McNamara was not only strongly opposed to any deductible in Medicare, but to any income test. A number of other issues relating to the Older Americans Act and the Elementary and Secondary Education Act resulted in his criticism of my views and official positions.

I went with the President because my son Christopher was graduating. Former Governor G. The President, however, never instructed me on how to handle Senator McNamara. None of the participants on the plane defended my position.

The inclusion of Medicaid in the law would not have occurred without the explicit support of Chairman Mills. Title XIX was not a secret, but neither the press nor the health policy community paid any attention to it because of the dazzling bewilderment of the adoption of Part B.

The proponents of Medicare were delighted with their victory; the opponents were demoralized. Those of us concerned with the legislation became preoccupied with the Senate amendments and the Conference Committee compromises. The full awakening to the scope of the Medicaid legislation did not come until much later.

The health policy community in was a small band of brothers and sisters concerned about the controversial elements in Medicare and unaware of the possibilities inherent in Medicaid. But the idea of Medicaid developed in my mind as early as I waited for the right time when someone would ask me to develop it into a law. The year was that time.

I included this provision in the Medicaid law because I was acutely aware of the inadequacies of the State medical assistance plans in the 's. I knew we had to start from where we were, but my hope was to broaden and improve the program over a year period. There was no opposition to this ambiguous and general provision in However, the attempt to implement this provision met resistance in New York State.

Governor Nelson Rockefeller opposed its enforcement because of the cost, and the provision was repealed at his request in the amendments. I have always thought this was an unfortunate and backward step. As I look back on the 45 years I worked on health policy issues, programs, and policies and, especially, the Medicare-Medicaid period , I see the Medicare and Medicaid legislation of as part of a long-time process—a continuation from the past, a creation in a particular moment of time, an incremental evolution for the future.

There have been some improvements since , some setbacks, and some changes whose eventual impact is still unclear. We have learned much in the ensuing 20 years. I do not see the legislation in terms of good or bad, right or wrong, or in terms of an expanded or restricted role of the Federal Government. The Federal Government's intervention was necessary and desirable in It was not the only form that intervention could have taken.

If the States had taken action during the period , the roles of the Federal and State governments in health and medical care economics might have been different today.

But individual States were unable to take up the opportunity in the face of the competitive costs to the employers in those States which enacted laws before others did. If the private insurance industry had supported specific proposals, which both the Republicans and Democrats offered during , the current situation might be different.

But they did not. They waited. They postponed action. They argued for delay. Time was running out. Today, Medicare and Medicaid are part of a nationwide safety net. What their role will be in the future depends on many factors.

But I am happy to have played a role in bringing these programs into being and giving a challenge to the health delivery sector of our economy to do better for present and future generations. I believe we will build a better program on the basic foundation of Medicare and Medicaid.

Detailed commentary on the legislative struggle is presented in a dozen oral histories, Columbia University Library, New York City, summarized in Corning It is comparable to a waiver of premiums in private life insurance policies, which provides for a paid-up life insurance policy at the time of disablement without payment of any future premiums.

The disability freeze was first enacted in the Social Security Amendments of , but it never went into effect. I had suggested this unusual compromise provision to Representative Wilbur D. Mills Truman, An operative provision was enacted in the Social Security Amendments of A careful study of public sector reimbursement policies and history before is needed.

No responsible person that I know of suggested a practical and acceptable alternative to reasonable costs or reasonable charges during the discussions.

The AMA has been supportive of the principle of Federal financial assistance for maternal and child health and crippled childrens' services since and to the elderly poor since the Kerr-Mills bill of The position remains unexplained even to this late date. From a practical point of view, the idea came from Merrill G. Copies of these memos are in my possession, along with numerous other documents on Medicare and Medicaid.

My dealings on any substantive matters were exclusively with Larry O'Brien of the legislative staff, and his assistants, Harry Hall Wilson and Mike Manatos. In the Kennedy Administration, however, I discussed substantive issues with Theodore Sorensen, the President's assistant. The Eisenhower-Flemming proposal of S. The authorization for vendor payments in did not refer to costs. Total hospital payroll thus assumed an increasingly larger share of hospital expenses.

National Center for Biotechnology Information , U. Health Care Financ Rev. Copyright and License information Disclaimer. Copyright notice. This article has been cited by other articles in PMC. Abstract Wilbur J. Introduction To place my present-day comments in historical perspective, it must be appreciated that I spent 15 significant years of my life helping to design the basic framework and pilot through the Congress 1 what became known as Medicare and Medicaid.

The beginnings In the following discussion, I will selectively recall and examine some provisions in Medicare and Medicaid that have not been previously discussed, and for which I participated in the decisionmaking process. Congress, 6 The primary source of my early and long association with Medicare is that I suggested it to Oscar Ewing in as a fall-back position after the defeat of the Truman national health insurance proposal and the Wagner-Murray-Dingell bill to carry it out.

Legislative process: The influential Wilbur J. Implementation The hospital part of Medicare had been in one or another stage of staff discussion since when the first Federal nationwide hospital insurance bill had been introduced in Congress Brewster, and Evolution of Medicaid The basic pressure for a Medicaid-type program began to develop in when Rhode Island wanted to utilize some of the existing public assistance funds under the Social Security Act for direct payments to vendors of medical care.

Summary As I look back on the 45 years I worked on health policy issues, programs, and policies and, especially, the Medicare-Medicaid period , I see the Medicare and Medicaid legislation of as part of a long-time process—a continuation from the past, a creation in a particular moment of time, an incremental evolution for the future. Footnotes 1 An extensive legislative history of the Act is provided by Cohen and Ball and Cohen and Peerboom References Brewster AW.

Division of Program Research. Social Security Administration. Washington: U. Government Printing Office; Chicago: Chicago Review Press; Washington: Public Affairs Press; Social Security Amendments of , Summary and legislative history.

Soc Sec Bulletin. Office of the Secretary, U. Department of Health, Education, and Welfare. The Social Security Amendments of Hospital Administration Oral History Collection. Chicago: American Hospital Association; Office of Research and Statistics, U. Department of Health, Education, and Welfare; Government Printing Office. Research Report No.

Westport, Conn. A Sacred Trust. Personal communication. They wanted, in particular, to make sure that children on welfare, who, in fact, made up the single largest category of welfare beneficiaries, had access to health care. Hence, they developed what they called the Child Health and Medical Assistance Act for consideration in the administration's legislative program. In creating what became Medicaid, he managed to incorporate elements of proposal that had been pushed by the AMA, known as Eldercare, into the large omnibus legislation.

The administration acquiesced in this request, but thought of a program like Eldercare as a supplement to Medicare rather than as a substitute for it. Medicaid made it into the law as a supplement, but one that would play a key role in the future of health care finance.

Medicare and Medicaid were the primary, but by no means only, ways in which the Federal Government became involved in the field of health care finance. Ever since universal health care had become a significant social policy ideal in the twenties, reformers had been interested in what Derickson has called the supply-side solution to the problem of access to medical care.

This solution concentrated on insuring that an adequate number of doctors and hospitals were available to treat and serve patients. Beginning in the forties, the Federal Government made significant investments in what might be described as the medical infrastructure. These included grants to the States for hospital construction in a program, known as the Hill-Burton program, started in and expanded many times after that, and subsidies for medical research and medical education.

Unlike national health insurance, Federal grants for these purposes attracted little political opposition, as increasing congressional appropriations for the National Institutes of Health in the forties, fifties, and sixties indicated Strickland, They were a consensus item in health policy, supported by both the proponents and opponents of Medicare. At the same time that Medicare was passed in , the Johnson administration also was interested in a program designed to counter the risks of heart disease, cancer, and stroke.

Variations of each of these proposals became law during the same session that Congress passed Medicare. One might argue that what led up to Medicare is irrelevant and that what matters is the shape of the final Medicare law and the ways it has been subsequently amended to reflect the predilections of policymakers from the era of Richard Nixon to the era of George W.

After the passage of Medicare and Medicaid in , controversy over national health insurance quickly yielded to consensus Oberlander, ; Feder, Items that might have been controversial, such as whether or not the elderly would elect the voluntary Part B coverage for Medical bills and accept the resulting deductions from their Social Security checks, proved not to be.

Instead, the Social Security Administration conducted a media blitz and sold the public on the idea that Part B was a good deal. These efforts were so successful that the voluntary feature of the program became almost insignificant, since nearly everyone elected to receive Part B coverage Berkowitz, As for the doctors who had worried about Federal interference in the private practice of medicine, they discovered, particularly in the years between and that Federal administrators honored their intention not to interfere.

To be sure, the Federal administrators made demands of private hospitals and private medical practitioners, as in the insistence that any hospital that received funds from Medicare should be racially integrated. But the law tempered such demands with a very permissive method of cost reimbursement that allowed hospitals and doctors to capture nearly all of their costs in treating elderly patients Feder, If anything, Medicare and Medicaid made doctors richer and preserved their autonomy, rather than making doctors' wards of the State.

Partly as a result of the money that Medicare pumped into the system, doctors became solid members of the upper middle class. Gone forever were the depression days in which one third of the physicians in the U. Despite this initial lack of political conflict in the Medicare and Medicaid Programs, tension ultimately arose that recapitulated some of the themes of the historical transformation of health insurance in the twentieth century and the political debate over Medicare in the sixties.

Medicaid, for example, emerged in as a program aimed at the poor and administered by the States. In these respects, it resembled the concept of sickness insurance that had been prevalent in the progressive era, although it covered the costs of health care rather than providing temporary disability insurance and it did not reach the entire working class, just those members of it who happened to qualify for welfare. Over the past 40 years and in particular since the s, Medicaid has expanded beyond its roots as a welfare program to cover more people in need of medical services.

In , Congress widened the scope of the program to cover pregnant women and children living in families with incomes nearly percent above the Federal poverty level Morgan, As a result of such actions, a State program endures, even thrives, as a major component of the U.

Suggestions that the Federal Government take over the Medicaid Program arise periodically, as in when President Reagan suggested that the States take over the Aid to Families with Dependent Children Program and that the Federal Government pick up all the costs of Medicaid Berkowitz, However, none of these suggestions have moved beyond the proposal stage.

As for Medicare, it was modeled on health insurance practice that was current in in ways that respected the contribution that the private sector had made to health care delivery and finance. No one in Congress seriously proposed that the Federal Government should get directly involved in the health care business by operating hospitals or drafting doctors into national service. The program also reflected some of the wisdom of Falk et al.

The doctor who treats a patient does not also have the right to certify him or her for disability benefits Berkowitz, Furthermore, Medicare was a national program, rather than a source of funds for State programs. Still, the story of Medicare over the past 40 years has been one of experimenting with elements of choice and of cost containment while trying to maintain the quality of care for the Nation's elderly.

State waivers, which permitted variations in practice from State-to-State, figured prominently in the development of Medicare in the seventies and eighties. The program's demonstration waiver made it possible for States to test the prospective payment system for hospitals that ultimately became a formal part of the program in Shirk, The prospective payment system itself reflected a major change from the Medicare cost-reimbursement model that prevailed in the program's early years.

Its creation reflected the fact that, despite the deference paid to private health practitioners in , the law became much more regulatory in its approach as time progressed. Increasingly, the government wanted to reign in the costs of medical care, of which Medicare and Medicaid were prominent components, by providing financial incentives that encouraged effective, but less costly care. Liberals worried that rising costs would crowd out the funds available for the expansion of the program to cover groups other than the elderly or to pay for new types of benefits such as prescription drugs or long-term care.

Conservatives, who were opposed to the idea of government regulation, nonetheless saw the need to reign in costs. Hence, prospective payment in the form of diagnosis-related groups to cover the costs of treating Medicare patients in hospitals became a feature beginning in , and prospective payment for doctor fees soon followed in Oberlander, After the element of choice, which had been so important in the debate over Medicare between and , also resurfaced.

At first policy insiders were confident that, if there was ever to be a Medicare Part C, it would be an extension of the program so that it covered people in different age groups, such as children or people in their fifties Berkowitz, The events immediately following passage of Medicare appeared to confirm this expectation, as the expansion of the program to cover beneficiaries of social security disability insurance and people with end stage kidney disease in seemed to indicate.

Yet, a Part C that would be America's national health insurance program that assured all Americans' access to medical care continued to elude policymakers, even in periods, such as the early seventies, when the passage of such a program appeared, if not likely, then at least plausible Berkowitz, As matters turned out, Part C took a long time to arrive and when it did it was something completely different than what the creators of Social Security would have expected.

Explaining the new program to seniors, a financial journalist reflected the popular understanding of Part C's purpose. Hence choice, such as Javits and Lindsay might have favored, was once again in vogue. The decision to link public financing of medical care and private health care plans run by private companies was also a prominent feature of Medicare Part D. This feature of the Medicare law arrived in as part of the Medicare Prescription Drug, Improvement, and Modernization Act of It laid the groundwork for a prescription drug benefit for seniors and people with disabilities on Medicare, something that reformers had sought as early as As created in , the benefit featured a scheme that allowed Medicare beneficiaries to enroll in private plans that would contract with CMS to provide prescription drugs to patients.

Here was another feature that took a different form than most would have expected in , but that Javits and Lindsay would have found congenial Henry J. As a historical piece this article has dwelled on the transformation of the idea behind national insurance during the period from to As demonstrated in this article, such modern phenomena as State management of health care finance programs, consumer choice over the type of health care plan an individual elects to join, and collaborative efforts between the public and private sectors to provide vital services all have their antecedents in the long debate over the passage of Medicare in Specific acts, such as Mills' decision to blend Republican and Democratic approaches to health insurance, have shaped the development of Medicare and Medicaid over the course of their 40 year histories.

In a more general way, the long run transformation of health insurance between the progressive era and the great society has also left its mark on the programs. These programs, whose anniversaries we celebrate, have therefore, resulted from a complex process of continuity and change.

The author is with George Washington University. E-mail: ude. National Center for Biotechnology Information , U. Health Care Financ Rev. Edward Berkowitz. Copyright and License information Disclaimer. Copyright notice. This article has been cited by other articles in PMC. Changing Concepts of Health Insurance Progressive Era In the progressive era at the beginning of the twentieth century, reformers with an interest in labor legislation understood what we now call health insurance to be something called sickness insurance.

New Deal Era In the face of political difficulties and the opposition of the medical profession, reformers continued to study the measure in the next two decades. Health Insurance in the Fifties These problems led to yet another iteration of the national health insurance idea during the fifties. Medicaid In the high profile negotiations over Medicare, what ultimately became known as Medicaid took a back seat. Medical Infrastructure and National Health Insurance Medicare and Medicaid were the primary, but by no means only, ways in which the Federal Government became involved in the field of health care finance.

Past as Prologue One might argue that what led up to Medicare is irrelevant and that what matters is the shape of the final Medicare law and the ways it has been subsequently amended to reflect the predilections of policymakers from the era of Richard Nixon to the era of George W. Conclusion As a historical piece this article has dwelled on the transformation of the idea behind national insurance during the period from to Footnotes The author is with George Washington University.

Record Group. National Archives; Washington, DC. Box The Formative Years of Social Security. Berkowitz E. Disabled Policy: America's Programs for the Handicapped. University Press of Kansas; Lawrence, Kansas: Robert Ball and the Politics of Social Security. Johnson signed Medicare into law in As of , nearly Medicare per-capita spending grew at a slower pace between and Today's Medicare Poll. Yes, I've already comparison shopped and selected the best option.

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