Medicare and Medicaid at 60: Need more -- and more threatened -- than at 50!

Ten years ago, on August 2, 2015, I posted Medicare and Medicaid at 50: Time to include “US” all on the 50^th anniversary of Medicare and Medicaid. I lived in Kansas City, and with local pride noted that the legislation was signed by President Lyndon Johnson on July 30, 1965 at the Truman Library in Independence, MO, just outside KC, with President Truman and Mrs. Truman present. They received Medicare cards #1 and #2. There was reason for this symbolism; President Truman had tried to pass a national health insurance program in 1945, but it failed, confronting the shameful opposition of the American Medical Association. In some major ways, his proposed program was more ambitious than even Medicare and Medicaid together would end up being, as it would have covered 85-90% of Americans (it would, however, have been voluntary; opponents could have chosen not to pay in and thus not be covered). In 1946, the Republicans took over Congress and so the proposed legislation was dead, Republicans historically (and currently) opposing anything that benefits most of the American people.

President Lyndon Johnson signing the Medicare and Medicaid Acts with former President Harry Truman at the Truman Library in Independence, MO, in 1965. Ironically, Lyndon Johnson himself never made it to Medicare age, dying in 1973 at age 64.

Medicare provided universal health insurance to seniors, who had previously lived their last years in fear that they would get sick and be bankrupt and unable to afford care, as well as people with some serious disabilities including blindness. Medicaid, a different program funded by a federal-state partnership, with the federal government paying usually more than 50% and up to 90% depending on the average state income, was meant to cover the poorest Americans. Of course, each state set both the eligibility standards (how poor you had to be, and what else you had to be besides poor) and the benefits. And, of course, many states set standards well below the poverty level and provided very limited benefits.

A few years before that 50^th anniversary, in 2010, Congress passed, and President Obama signed, the Affordable Care Act, ACA, also known as Obamacare, which significantly expanded access to health coverage. One major component of the law was the establishment of insurance exchanges where individuals who were previously uninsured could purchase health insurance at group rates, which were more affordable than had previously been available to individuals. The other important component allowed states to expand their Medicaid programs to people who made too much money to have previously been eligible. This part was supposed to fill in the gap and cover those who, despite making too much for Medicaid, still were too poor to qualify for the ACA exchanges, and this was a lot of people. Remember, Medicaid did not cover people who were just poor (even really really poor); you had to be, as stated by Dr. Bridget McCandless, the CEO of the Health Care Foundation of Greater Kansas City at that 2015 event, “poor and…”:

Poor and pregnant, poor and the mother of small children, poor and disabled, poor and in a nursing home, poor and – and the tears rolled down her cheeks – a child.

As I have noted before, despite the lying propaganda put out by Republicans before the passage of HR 1 (the “Big Beautiful Bill”) this year, few Medicaid recipients are able-bodied but unemployed childless adults. Most are small children and their mothers or disabled or in nursing homes – and nursing homes, almost all of which are privately and profitably run, account for most of the money spent. By the way, neither Missouri nor Kansas (the other state in the Kansas City region) took the opportunity to expand Medicaid, even though the federal government would have initially paid 100% and after a few years 90% of the cost, so some of its citizens simply continued to suffer and die.

However, despite this, in the opinion of most Republicans in Congress, too many people were getting health care, and it was costing too much money which could otherwise be used for more important projects, mainly cutting taxes on the wealthiest people in this country. This “problem” is being addressed by HR 1, which will, according to the Congressional Budget Office, result in about 11 million people losing Medicaid coverage. Of course, this is denied by some; Vice President J.D. Vance said “Don’t believe every false media report that you’ve heard, because our explicit goal in the Trump administration is to protect people’s healthcare.” You can either believe him just saying that based on no data, or believe the CBO, or you can wait and see. Also, many Congressional Republicans expressed great concern about the bill’s impact on Medicaid, including my Congressman, Juan Ciscomani (AZ-6), but voted for it anyway. Note: voting for a bill with reservations is the same as voting for a bill!

Medicare will also be significantly (negatively) impacted by HR 1, as discussed in detail by the Commonwealth Fund. They address primarily low-income Medicare recipients with disabilities (arguably a particularly vulnerable group!) who have been eligible for assistance programs that help pay their Part B (outpatient) and Part D (drug coverage) premiums. HR 1 makes it possible for states to create additional obstacles to becoming enrolled in these assistance programs. A lot of Republicans have also talked about the tax savings people will get from Medicare payments, but it will not be very much, and benefit few:

Tax changes for people age 65 and older. The law includes a $6,000 annual tax deduction for adults over 65 with taxable incomes up to $75,000 annually ($150,000 for those filing jointly), with smaller deductions for those making up to $175,000 ($250,000 filing jointly) for 2025–2028. Low-income older adults generally do not make enough taxable income to be eligible for the deduction, but the provision could help middle- and higher-income older adults. The CBO has not separately estimated the cost of this deduction.  [Commonwealth Fund] 

Then there are the rest of us on Medicare. Another major Republican passion is privatizing both Medicare and, indeed, Social Security. Mostly they don’t like to talk about it openly because these are the two most popular programs in the nation, but that is what they are working on. And sometimes one – often a billionaire Cabinet secretary who hasn’t the slightest idea of how regular people live (are there any others?) -- slips up and says just that. In this case it was Treasury Secretary Scott Bessent who told us that the “Trump Accounts” for children were literally a “backdoor” for privatizing Social Security. And they also come in through the front door. The “Medicare Advantage” program is one of the main mechanisms for doing this; it is not Medicare (it takes the Medicare dollars that would provide for your care and pays them to an insurance company that basically puts you in their HMO or PPO) and is only advantageous for some recipients, mostly those who are not too sick. Note that these plans can vary a lot – in general government retirees are in better plans than those from the private sector – but the key issue is that rather than being in Medicare, which has to cover you, you are in a private insurance program which can – and does – often deny your claims, as it does for the non-Medicare insured. (see for example my posts "It was the best of times, it was the worst of times": Threats to the public's health from Medicaid cuts, MAHA, and others, Jun 7, 2025, and Open Enrollment Season for Medicare and Medicare Advantage: What you should know, Oct 7, 2024).

In 1945, under President Truman, the American people needed comprehensive universal health coverage. In 1965, under President Johnson, they still needed it, and some of the most vulnerable Americans, the elderly and poor, got Medicare and Medicaid. In 2010, under President Obama, they still needed it, and got some expansion of coverage from the ACA. In 2025, under President Trump, they need it more than ever, but the coverage that we do have is being deeply eroded. 

Meanwhile, the people of every other wealthy country have universal health care, longer lives, and better health outcomes, and it costs them way less! Are we such suckers?

 

 

 

Medicare and Medicaid at 50: Time to include “US” all

On Thursday, July 30, Medicare and Medicaid turned 50 years old. The anniversary was marked by an event held at the Truman Library in Independence, MO, which I attended. Why there? In 1965, President Lyndon Johnson signed those bills (officially Titles XVIII and XIX of the Social Security Act) there, in the presence of former President Truman and his wife Bess, who received cards #1 and #2. The location was chosen for its symbolism even in 1965, because Truman had fought for a national health insurance system and lost. Nearly 20 years later, Johnson honored his legacy by signing these two major bills (also opposed by the AMA) in his library. Both presidents thought that this was a down-payment on the national health insurance system that was sure to come soon. But it took another 45 years to pass the Affordable Care Act (ACA), and we still don’t have universal health insurance, and ACA and even Medicare are under constant attack. At least now it is not the AMA that is the active opposition.

This event was not the first held at the Truman Library to remember that day. Seven years ago, a group of single-payer activists organized a 43^rd anniversary celebration there, both to commemorate the signing and to call for a universal health insurance system. That event was less “official” but more passionate, with talks by both local KC Congressman Emanuel Cleaver II and Rep. John Conyers of Michigan. Rep. Conyers’ first year in Congress was 1965, the year Medicare and Medicaid passed, and all those years later he was still vital and still in Congress and was the sponsor of HR 676, the national single payer bill. This year’s event had more of the feel of an administration press conference with several federal and Missouri bureaucrats speaking. Some of talks, including those by Truman’s grandson Clifton Truman Daniel and former Missouri state rep and insurance commissioner Scott Lakin, were good, but only one had any real passion. That was given by Bridget McCandless, MD, the CEO of the Health Care Foundation of Greater Kansas City (HCFGKC), which sponsored the event.

There is a reason for that. Before taking the reins of HCF, a “conversion” foundation established with the money that came from the sale of a group of not-for-profit hospitals to for-profit HCA, Dr. McCandless, a self-described “Independence girl”, was the medical director of the Jackson County Free Health Clinic in Independence, caring for the many people in that area who could not otherwise access excellent health service. She cared for people who had little, whose lives, in Dr. Camara Jones’ metaphor (most recently discussed in Racism and the Social Determinants of Equity: Camara Jones at Beyond Flexner 2015, April 19, 2015), were lived on the edge of the cliff before they even got sick. Dr. McCandless’ clinic provided a safety net that prevented many people from falling to the ground below. The “lucky” ones were those who were old enough (or disabled enough) to qualify for Medicare, and poor-plus-something enough to qualify for Medicaid. For those people, these federal programs, which now cover about 30% of Americans were indeed life savers.

Dr. McCandless, whose foundation is committed to funding programs that help the underserved and uninsured (the exceptional founding CEO, Steve Roling, was in the audience), talked, as did other speakers, about the difference that Medicare had made in the lives of seniors; before it they (and their families) lived their retirement years in financial fear of sickness. But her passion really showed when talking about Medicaid, originally seen as a means of providing access to health care for the poor. You certainly have to be poor to receive Medicaid, very poor in many states including Missouri, but that is not sufficient. She told us that you have to be “poor and”. Poor and pregnant, poor and the mother of small children, poor and disabled, poor and in a nursing home, poor and – and the tears rolled down her cheeks – a child. ACA was intended to expand this federal-state collaboration to encompass all the “just” poor (with the exception of those who are undocumented), but Missouri, and Kansas, the other state in the Kansas City metropolitan area, are among the states that have not done so.  Dr. McCandless eloquently expressed her hope that our states would rise to the need, that our legislators and leaders would rise to the decency, to remove the “and” by expanding Medicaid.

While it is possible that Missouri, and Kansas, and the other states that have taken advantage of the 2012 Supreme Court decision (National Federation of Independent Business v. Sebelius), that otherwise upheld the ACA, to not expand Medicaid will still do so, it is unconscionable that they have not yet, that they have left so many people who could now be accessing health care uncovered. It is a land-office business for the safety net clinics in the area, like Dr. McCandless’ former practice, but it is a volume that they can barely care for. When people get very sick, and show up in the Emergency Department and get admitted to the hospital, those hospitals bear the brunt of care without payment, but even their usually powerful lobbies have so far not been successful.

The opposition to this expansion, the opposition to ACA, and even threats to Medicare are often said to be politically driven, but they are ideologically driven. They are driven by the agendas of billionaire elitists, most of whom have never known any hardship. They have been able to further expand their already-considerable influence as a result of the Supreme Court’s Citizens United decision, and blithely fund the election of their minions to state houses and legislatures.  The New York Times on Aug 2, 2015 documents that fewer than 400 families have contributed the almost half the money in this election cycle. Former Oklahoma football coach Barry Switzer once said that many of the privileged were “born on third base and think they’ve hit a triple” (although most of these billionaires were actually born within arm’s length of home plate!). Indeed, they have no empathy; they are selfish and mean. Their minions, who enjoy the power their sponsors’ money provides for them, must be (if they are not truly stupid) also mean, but actually are not fiscally prudent; not funding health care for our people costs us a lot. Medicare already covers our most costly ill (they are old; this is why raising the age for Medicare eligibility to 67 or 68 will save little money). It is way past time for it to cover the rest of us.

Rep Jim McDermott of Washington, a physician and long-time single-payer advocate, has introduced the American Health Security Act of 2015, which will authorize and provide federal funds to support single-payer programs developed by states. It should be passed, but it probably won’t be while we have a Congress bought and paid for by the rich mean selfish people. We have had single-payer bills in Congress before, Rep. Conyers’ and before that Rep. Ron Dellums’. It is time to pass them. We need to go beyond the ACA, we need to make sure states expand Medicaid and take the “and” out of the “poor and” for eligibility. But we need to go farther.

For 50 years Medicare has been literally a life-saver for our seniors. Now we need to expand it to include everyone. Everybody in, nobody out!