Lisbeth B. Schorr, Center for the Study of Social Policy
It was early 1965 when I sat in on a meeting that was one of a series deliberating the final touches of the legislation that would soon be enacted as Medicare. Those gathered that day were the Undersecretary of HEW, Wilbur Cohen, the Commissioner of Social Security, Robert Ball, a representative of the White House whose name I can no longer remember, and the director of social security for the AFL-CIO, Nelson Cruikshank.
Wilbur Cohen reported on his latest inconclusive negotiations with Wilbur Mills, chair of the House Ways and Means Committee. He also reported with considerable enthusiasm that someone at the White House had suggested a novel way to deal with one of the troublesome issues still outstanding: how to decide on the hospital benefit to be covered. Should the benefit consist of 15 days of hospitalization with no coinsurance and no deductible? 30 days with a 3-day deductible? 60 days with a larger deductible and coinsurance? The solution that the Undersecretary was now advancing was to provide the beneficiaries with a choice among each of these.
I remember vividly how the soft-spoken Commissioner of Social Security rose from his chair to announce, in the strongest voice I had ever heard him use, that he would refuse to administer such a benefit. He was unwilling to ask retirees, a significant segment of whom were in their 80s and 90s, to struggle with that kind of a choice. He was also convinced that the complexities of administering such a program would threaten the Social Security Administration’s 30-year commitment to making every encounter between government and beneficiary one that inspired confidence because it was clear, smooth, and self-evidently fair. The choice-of-benefits idea was never proposed again.
While I’m fully aware that those who are making choices about their health insurance today are a more heterogeneous group than the over-65 Social Security beneficiaries of 1965, and that the capacity to deal electronically with that kind of decision-making has vastly increased (though perhaps not quite enough), I still long for the voice of Robert Ball. With his unwavering focus on assuring every American with a high quality experience in dealing with government, he might have saved us from some of the disappointments we experienced this October.
Right on.
That’s why Medicare
Right on.
That’s why Medicare could be implemented eleven months after it was enacted. Jim Morone reminds us that LBJ stated that it “was the largest mobilization of public resources since D-Day, since the launching of the invasion of Normandy.” Medicaid, a state administered program took much longer (Arizona did not enter the program till 1982!).
Simplicity v complexity; low administrative costs v high administrative costs; federal v state administration; social insurance v expansion of existing system: all these and more are sharp contrasts.
The computer glitches will be cleared up. The complexity and annual review of demographic and family data will remain.
Bob Ball was right then and would surely have had reservations about some of the characteristics of the ACA. Whether he would have prevailed today as he did in 1965 is quite another matter.
But it is great to be reminded of that very different time in our nation’s history.