The Three Things Medicare Did That Almost Nobody Gives It Credit For

You were not alone in that. Johnson flies out to Missouri, signs the bill inside Harry Truman's own library, and hands the man who spent twenty years losing that fight the very first card ever issued. That is a hard afternoon to follow on a Friday.

Which has always struck me as the wrong place to stop. The interesting question about any promise isn't whether somebody made it. It's what the thing actually did once it was real and out in the world. So today Ian gives us three of those, and the first one has nothing to do with medicine at all.

In the spring of nineteen sixty six, roughly seven hundred federal workers and volunteers fanned out across this country to inspect about two thousand hospitals inside of three months. And they were not there to check on the quality of the medicine.

Whether Black patients were being admitted. Because a hospital that discriminated could not take Medicare money.

That is what happened, and Ian was careful to lay out how, because the mechanism really is the whole story here.

Brown was decided in nineteen fifty four. And hospitals were still segregated a decade after it. It took until sixty three for a federal appeals court to rule that separate but equal in publicly funded hospitals violated the Constitution, in a case called Simkins versus Moses H. Cone Memorial Hospital.

And do you know how that case even started? A dentist in Greensboro, North Carolina had a patient with an abscessed tooth. The man needed hospital treatment and there was not one in town that would take him.

So the courts were moving on it. But here is the structural problem with litigation as a tool. You sue one hospital, you win, and then you start over and sue the next hospital.

Ian puts it in a single line. Litigation moves one hospital at a time. Money moves all of them at once.

Two pieces snap together. Title Six of the Civil Rights Act of nineteen sixty four says no institution that discriminates can receive federal funds. And Medicare, which switches on in the summer of sixty six, is about to become the largest single source of federal money any hospital has ever seen.

Ian's line is that it wasn't a lawsuit, it was a checkbook.

And then somebody had to go and actually look, which is the part I keep thinking about. That's who the seven hundred people are. They walked the halls themselves.

You could not, and they did not. The account in the National Institutes of Health archive says the inspectors leaned on local people, on civil rights activists, and on Black hospital employees telling them what was truly going on inside the building.

Enormous courage, and the inspectors needed them, because there was active deception going on. Administrators covered up signage. They moved patients around for the day. In some cases they falsified charts to fool the people walking through.

And then presumably put it all back the way it was the next morning.

By the deadline, ninety percent of the nation's hospitals and seventy percent of southern hospitals had met the desegregation standard.

Because of a retirement program.

And it isn't some new discovery either. The American Journal of Public Health published a study specifically about the federal use of Title Six and Medicare to integrate hospitals between sixty three and sixty seven. It is sitting right there in the scholarly record. It simply isn't in the version most of us were handed.

That Medicare stopped being only for the old, and it stopped a very long time ago. Most people assume the program has always meant sixty five and nothing else.

Nineteen seventy two. The Social Security Amendments that October extended it to two groups under sixty five. People who had been receiving Social Security disability benefits for twenty four months, and people with end stage renal disease.

Right. Coverage for both groups started on July first of nineteen seventy three, and roughly one point seven million people under sixty five became eligible on that day.

Just the one. If your kidneys fail, the federal government covers you regardless of your age. If almost anything else fails, it does not.

And I think that's the honest lesson sitting inside it. Nobody sat down and designed the modern shape of this program in one go. It got extended and argued over and patched, in exactly the same way it got assembled in the first place.

Same pattern the entire way through. Alright, number three, and this is the one that surprises people the most.

In nineteen eighty eight, Congress passed and President Reagan signed the Medicare Catastrophic Coverage Act. Biggest expansion of benefits since the program was created. It capped what you could be forced to pay out of pocket, and it added an outpatient prescription drug benefit.

On paper it's a gift, and his remarks from the signing are still on file at his own presidential library. Then people read how the thing was going to be paid for.

They were. The new benefits were financed by the enrollees themselves, through a premium increase that was partly tied to income.

That is where the whole thing broke. You're asking a large number of older Americans to pay more money for something a great many of them believed they already had.

Furious. And more to the point, organized. In nineteen eighty nine, in his own Chicago district, the chairman of the House Ways and Means Committee, Dan Rostenkowski, was confronted by a crowd of angry older constituents who surrounded his car and blocked it in.

Got out and left on foot. It became one of the most famous images in the history of American senior politics.

Congress repealed the law on November twenty second, nineteen eighty nine. Roughly seventeen months after passing it.

Not on that scale, as far as I could find. And Betty, notice which chair that man was sitting in.

On Wednesday we met Wilbur Mills, who held that identical chairmanship and built this whole program out of three warring bills overnight. Twenty four years later a different chairman of the same committee is running through a gas station to get away from retirees.

Beginning to end, it's always been that room.

Look at what moved things in each one. Hospitals did not integrate because a court finally found the right words. They integrated because the money was not going to arrive otherwise.

And the eighty eight expansion didn't fall apart because it was bad medicine. It fell apart over who was being handed the bill for it.

Every time. And Ian's point is that this is still true today, which is why any of it matters to somebody sitting in one of our offices this afternoon.

He says that from the conversations our advisors have every week, the decisions that go wrong around this program are almost never medical decisions. They're financial ones, made without enough information, usually under time pressure, and usually right at sixty five.

Which is the entire reason tomorrow exists.

A door that opens once, right around your sixty fifth birthday, and then closes in a way most people never discover until they go to walk back through it.

And there's a category of expense this program has never covered. Not in sixty five, not now. And it's the one most likely to do to a family today what hospital bills were doing back in nineteen sixty.

Tomorrow at ten thirty.