Today marks the 50th anniversary of the signing of the Social Security Amendments of 1965, which introduced Medicare and Medicaid into the American health care system. The programs currently enjoy widespread public support, with the majority of Americans indicating that Medicare and Medicaid, respectively, are “important to them and their family.” But the popularity of these programs stands in stark contrast to the political resistance they faced before their passage.
It is important to understand the ideological opposition to Medicare and Medicaid in the 1960s in order to put the current opposition to the Affordable Care Act, or ACA, into context. Changing public and political opinions about Medicare and Medicaid show that when programs effectively improve health care access, quality, and affordability, they become respected pillars of the American health care system and political landscape. The history of Medicare and Medicaid, which have been amended dozens of times yet never repealed, indicates that the ACA will grow and evolve within the nation’s health care framework. With the U.S. Supreme Court’s ruling in King v. Burwell making clear that serious legal and political challenges to the ACA are now over, the examples set by Medicare and Medicaid provide hope for the ACA’s future.
Early opposition to Medicare and Medicaid
Like Presidents Harry Truman and John Kennedy before him, President Lyndon Johnson met resistance when he inherited the cause of providing accessible health coverage. Although, in 1964, 61 percent of the American public approved of an insurance program that would cover “hospital and nursing home care” for seniors, there were fervent political calls to keep the government out of health care. Future President George H. W. Bush called Medicare and Medicaid “socialized medicine,” and future President Ronald Reagan opined that if Medicare were passed, “one of these days, you and I are going to spend our sunset years telling our children and our children’s children what it once was like in America when men were free.” In 1964, presidential candidate and then-Sen. Barry Goldwater dismissed government medical care for pensioners as being equivalent to free vacation resorts or free rations of cigarettes and beer. Yet, the free vacation resorts did not materialize—and the end of freedom never came.
Medicaid, which initially only provided health care coverage to low-income children and people with disabilities, received less political attention than Medicare. As a joint federal and state program with optional state participation, its early story differs from that of Medicare, which was mandatory and implemented immediately at the national level. While resistance to Medicaid from some conservative states lasted into 1969, nearly every state was participating within four years of its passage. Alaska joined later, in 1972, and Arizona held out until 1982. Opponents, however, continued to push a public image of Medicaid as a “stigmatized charity benefit,” and the early Reagan administration enacted harsher eligibility restrictions.
Medicare and Medicaid as part of the American experience
Notwithstanding the misplaced fears that they would destroy American freedom, Medicare and Medicaid have been indispensable parts of the American health care system for the past 50 years. Immediately after its passage, Medicare provided coverage to 19 million elderly Americans. In 1964, only half of all seniors had health insurance—a statistic that jumped to 96 percent after Medicare was implemented. Just a few months after Medicare was signed into law, about 8 in 10 Americans approved of it. The conversation shifted from whether Medicare and Medicaid should exist to how they could be improved.
Despite President Reagan’s strong opposition to the original bill, during his presidency, he signed bipartisan legislation that dramatically expanded Medicare. President George W. Bush heavily campaigned for and eventually signed legislation to create Medicare Part D, which covers prescription drug benefits. Under the Reagan and George H. W. Bush administrations, Medicaid expanded to cover pregnant women and children—an expansion that was later supplemented by the creation of the Children’s Health Insurance Program, or CHIP, under the Clinton administration. In 2014, Medicare and Medicaid provided health coverage to about one-third of the U.S. population.
The programs have evolved since their passage, shaping the way that states and the federal government provide health coverage to millions of citizens. Since the ACA’s implementation, Medicaid enrollment has grown more than 20 percent, and Medicare has taken historic steps to lower costs and continue to improve the quality of care its participants receive. The U.S. Department of Health and Human Services, for example, recently announced a proposal to expand bundled payments for orthopedic procedures in hospitals.
The ACA is following a familiar road
Like Medicare and Medicaid before it, the ACA faced many political attacks during its inception. The individual mandate for coverage and the expansion of Medicaid vastly increased coverage across the nation, but they were also politically volatile. Rep. Steve King (R-IA) called the ACA a “malignant tumor that is metastasizing and feeding on God-given America liberty.” Rep. Michele Bachmann (R-MN) said that the ACA should be repealed “before it literally kills” women, children, and senior citizens. And ironically enough—given his many proposals to privatize Medicare—Rep. Paul Ryan (R-WI) asserted that the ACA “ends Medicare as we know it.” In 2013, Sen. Ted Cruz (R-TX) told Fox News that he worried that if the ACA passed, people would get “hooked,” and Congress would lose support to repeal the law.
Because full implementation of the more tangible coverage benefits of the ACA did not occur until the start of 2014, it remained an easy target for criticism longer than Medicare did. All of this rhetoric spread while the consequences of repeal were not clear to the American public. Today, however, an estimated 16.4 million people have gained coverage under the ACA, making it the largest expansion of health coverage since the enactment of Medicare and Medicaid. As states recognize the benefits of signing on, more and more have agreed to the ACA’s Medicaid expansion, much as they did with the original Medicaid program.
It is now clearer than ever that health reform is here to stay. As President Barack Obama proclaimed after the King v. Burwell ruling: “This is not an abstract thing anymore. This is not a set of political talking points. This is reality.” Just as it did with Medicare and Medicaid, the political conversation surrounding the ACA must move beyond repeal and turn toward serious debates about how to improve and shape health care for future generations.
Justin Morgan is an intern with the Health Policy team at the Center for American Progress. Special thanks to Thomas Huelskoetter, Maura Calsyn, and Rupali Srivastava for their comments on this column.