Medicare turns 50 – top health officials reflect on its past and future

Today, July 30th, is the 50^th anniversary of the day President Lyndon Johnson signed Medicare into law.  Since its enactment in 1965, the program has changed the course of American health care.  Two former high-ranking government health officials, an adviser in the Reagan administration and a health commissioner for the City of Philadelphia, reflect on where this crucial program stands after half a century.

Glenna Crooks, PhD was Deputy Assistant Secretary for Health and worked with Secretary (and former Pennsylvania Senator) Richard Schweiker in the administration of President Ronald Reagan.  She is currently a health care advisor to businesses and governments globally and the founder of a tech start-up that will launch next month.

Walter Tsou, MD is former Commissioner of the Department of Public Health for the City of Philadelphia and past president of the American Public Health Association.  He is currently Adjunct Professor of Family and Community Health at the University of Pennsylvania.

Medicare @ 50 has much to celebrate

By Glenna Crooks, PhD

Happy Birthday Medicare!

So much has changed since you toddled out into the world 50 years ago.

Back then, there were only 20 million seniors. Their life span was much shorter than today. Men could expect to live to 67; women to 73. You planned to cover their health care costs for only five years (on average) and cost projections weren't that high. After all, health care couldn't do much in those days. Antibiotics were available, but the nation had few vaccines and not many medicines. Emergency medical systems, physician manpower and hospital services were limited. Racial segregation created barriers to access for minorities. Government was only beginning to invest in biomedical research with the first great surge of funding for the National Institutes of Health.

In the years since, public health achievements like vaccines, tobacco control, improved maternal-infant health and seat belts reduced accidents and preventable causes of death. People began to live longer, healthier lives. Biomedical research created new therapies: organ transplants, kidney dialysis, ultrasound, CT and MRI imaging, lithotripsy, artificial joints, cochlear implants, treatments for rare diseases, implantable defibrillators, and drugs like insulin, statins, oncolytics and antivirals. The quality of life for seniors improved markedly. At the same time, the Civil Rights Act of 1964, desegregation and Community Health Centers improved health care access for minorities.

As a result, today you serve a population of seniors that has more than doubled in size and will continue to grow. On average, this year's new boomer enrollees can expect to live to age 84 if they're men and 86 if they're women. But those are just averages; 25% of them will live past 90. They'll be beneficiaries for at least 15 years.

The cost to serve more seniors with more technology seems daunting, but the news is not all bad. There's good news, too. We've long known that those who are wealthier are healthier. The converse is also true. The healthier a person is, the wealthier they will become. Health care is not just a cost in a personal – or national – budget. It's an investment. Health and wealth are linked. It's a good way to invest.

The nation is realizing those health-and-wealth benefits today. Compared to seniors in 1965, today's are more educated, more likely to be employed, wealthier, heathier, less likely to be disabled, and more likely to live independently.

Today's seniors contribute to the economy in many ways even if they're not in the workforce. They are energetic, engaged volunteers in their communities and serve in hospitals, soup kitchens, schools, businesses, and sports. They also include a growing group of entrepreneurs; 20 million plan to start companies or non-profits in their retirement. Some provide care for others in the family, with an annual economic value of those efforts between $234 billion to 450 billion (depending on whether you believe CBO or AARP's numbers). Those are costs the public purse won't need to cover.

Yes, there's good news and good reasons to have a Happy Birthday, Medicare!

Medicare and Medicare have worked wonders, but we need true national health insurance for everyone

By Walter Tsou, MD

By the early 60s, America was in the throes of the civil rights movement led by its charismatic leader, Rev. Martin Luther King. Discrimination and Jim Crow laws applied not only to bus rides and dining rooms but also to hospital wings and doctors' waiting rooms, which often had separate curtains for blacks and whites. As it turned out, separate but equal was a failure not only in education, but in health care, too. Well before we started to measure health disparities, it was well known that minorities suffered far worse health outcomes.

But nothing shook the nation quite like the assassination of John F. Kennedy in 1963. With the overwhelming mandate of completing Kennedy's unfinished agenda, President Johnson signed the Civil Rights Act in 1964 and the laws creating Medicare and Medicaid in 1965. Led by Wilbur Cohen, who had been the Assistant Secretary of Legislation in the Department of Health, Education and Welfare (HEW) under Kennedy and later Secretary of that department under Johnson, the architects of these laws saw them as a first step toward true national health insurance. To those who created Medicare and Medicaid, national health insurance would not only be a way to end separate but equal in waiting rooms, but also to establish health care as a right of all Americans.

But there was strong opposition by southern legislators as well as many physicians and private insurers. As a result, Congress settled for health insurance only for the elderly (Medicare) and for the very poor who were aged, blind, or disabled (Medicaid). Because Medicare was designed as a companion program to Social Security, 20 million seniors were auto-enrolled in 1965 in one year. (Compare that to the disastrous enrollment problems in October 2014 with the ACA with its complex eligibility rules.)

Fifty years later, Medicare and Medicaid have proven themselves as the most successful health programs in American history. They have given hundreds of millions of Americans access to care and have allowed tens of millions of them to avoid bankruptcy due to medical debt. Equally important, Medicare ended physical separation by race in doctors' waiting rooms in most of the South, although much provider racial discrimination still persists.

Unfortunately, the failure to enact true national health insurance for everyone has led to our current patchwork health care financing system that is unimaginably complex, bureaucratic, and inefficient. The system continues to base access to health care on employment, income, and disease category, which indirectly reflect race. Even today, the black infant mortality rate in the United States overall, as well as in Philadelphia, is more than twice the rate for whites.

Money wasted determining eligibility for coverage could be used to cover everyone. The amount of money wasted on administration in the United States is more than 40% higher per capita than in any other country in the world. It is more than enough to fully fund our schools, build bridges, and address other public priorities.

Wilbur Cohen, while defeated in his goal of achieving national health insurance for everyone, said that he believed in the "salami" approach - getting one slice at a time until there were enough of the pieces together to cover everyone. Fifty years later, it is time to make his dream a reality.

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