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?

 

 

 

Trump, Price, and Verma: Bad news for the health of Americans, including Trump voters

The election of Donald Trump as President continues to be extensively analyzed. It demonstrates major divisions among our populace. One of those that has been discussed a lot is that the “white working class” that voted for him by a 2:1 margin will suffer a lot from the policies likely to be implemented by his administration. Not more, and probably less, than minority people, but a lot.

Healthcare and health insurance is one of those areas, as discussed by me in several recent posts and by Paul Krugman in the New York Times, December 2, 2016, “Seduced and betrayed by Donald Trump”. He notes that anger about their health care coverage, and in particular the dramatic increases in premiums under the ACA exchanges, drove many people to choose Mr. Trump’s promise to replace it with “something terrific”. Of course, he never specified what that would be, for the same reason that the Republicans in Congress have never been specific, which is that any replacement plan that does not move “left” toward a more universal coverage plan such as the single-payer advocated by Senator Bernie Sanders (and me) will be much worse for most people, including most Trump voters, who will either lose or have to pay a lot more (if they can!) for their health insurance coverage. Repealing Obamacare means that many of the 13 million newly insured (a majority white, for the record) who received insurance under the exchange will not get rate cuts, but rather they will get no coverage. Certainly not those who need the insurance most, because they have pre-existing conditions that insurance companies were mandated by ACA to cover. As Krugman puts it, “we’re probably looking at more than five million Trump supporters, many of whom have chronic health problems and recently got health insurance for the first time, who just voted to make their lives nastier, more brutish, and shorter.” This is made clear in the Times article on December 3, 2016 “GOP plans immediate repeal of health law, then a delay” by Robert Pear, Jennifer Steinhauer and Thomas Kaplan. The reason is because the only plan they have will yank health insurance coverage for so many people, and despite their vociferous opposition and multiple votes to repeal ACA, they do not want to do that, at least right away.

The best evidence for their long term plan to, basically, remove health insurance coverage from many Americans including their base of support is the appointment of Rep. Tom Price (R, GA) as HHS Secretary. Mr. Price has been a leader of the Tea Party movement and a major Congressional figure calling for the repeal of Obamacare. His solution is not completely fleshed out, but does include eliminating guaranteed issue, community rating, and federal support for the exchanges. He is a fan of vouchers, an idea advocated for decades by conservative think tanks, and which, I guarantee (and this is far more of a certainty than Mr. Trump’s promises), can NEVER work, especially over the long term. Vouchers will never cover the cost of a decent insurance policy; people with health problems will naturally be the first to seek coverage, and faced by the adverse selection insurers will raise the premiums, co-pays, and deductibles for them. If there are problems with this under Obamacare, vouchers will make those look pale by comparison. And by getting out of the running-the-infrastructure business, the government will ensure that it never gets better.

Price, a wealthy orthopedist from suburban Atlanta, does not really care. He represents rich doctors who want to be able to charge whatever they want to be able to charge, and care only for the people who have insurance good enough to pay it. Sorry, Trump voters with not much money, chronic disease, and difficulty paying even ACA premiums, that isn’t you. And when you get to an age that you can get Medicare, finally having federally-supported coverage, Mr. Price has another answer for you – privatize Medicare! Make it subject to the same market forces that have made health care and health insurance so unaffordable and unavailable to younger folks affect the elderly too! The ACA has modified the egregiously negative impact of private sector health insurance for the under-65 group; the crumbum Price wants to both reverse that benefit and extend the damage to seniors too.

When Lyndon Johnson signed the Medicare law at the Truman Library in 1965, presenting Harry and Bess Truman with cards #1 and #2, he quoted the former President from nearly 20 years earlier: "Millions of our citizens do not now have a full measure of opportunity to achieve and to enjoy good health. Millions do not now have protection or security against the economic effects of sickness. And the time has now arrived for action to help them attain that opportunity and to help them get that protection." LBJ then added that “There are more than 18 million Americans [in 1965; way more now] over the age of 65. Most of them have low incomes. Most of them are threatened by illness and medical expenses that they cannot afford. And through this new law, Mr. President [referring to Mr. Truman], every citizen will be able, in his productive years when he is earning, to insure himself against the ravages of illness in his old age.”

This is what Tom Price and his colleagues want to reverse. The AMA, with its shameful history of actually having blocked Truman’s health plan, and unsuccessful opposition to Medicare, is endorsing him. The Association of American Medical Colleges (AAMC) is endorsing him as well. The American Academy of Family Physicians (AAFP) more tepidly expresses optimism. Presumably these are political decisions, to maintain access. After all, in the ongoing battles between insurers and providers (patients are rarely a real player), at least he is a provider. But many others, including Physicians for a National Health Program (PNHP) and Common Dreams, as well as the medical students of Future Docs, have appropriately condemned Price and these organizations endorsing him.

Mr. Price will be joined by Seema Verma, who will head the Center for Medicare and Medicaid Services (CMS). Verma helped Mike Pence design the Indiana version of Medicaid expansion. On the plus side, that state did expand Medicaid, helping people more than those states that did not. On the minus side, the requirement that everyone covered has to pay meant at least 1/3 of those who would have been eligible did not sign up. I guess she is the moderate!

Mr. Trump’s cabinet picks are, so far, a panoply of people who are either right-wing ideologues who wish to destroy everything that has been done to help the American people at least back to the Great Society and maybe to the New Deal, or are billionaires who speak for the corporate financial ruling class that he attacked so effectively during his campaign, or both. An example of the latter is anti-public education billionaire Betsy DeVos to head the Department of Education. Myron Ebell, a noted climate-change denier, will head EPA. Steven Mnuchin, a leading Goldman Sachs banker, will be Treasury Secretary. Senator Jeff Sessions (R, AL), denied a judgeship because of his racist beliefs and practices will be Attorney General. Trump's nominee for Commerce Secretary, Wilbur Ross, according to Money, alone has 10 times the net worth of the entire cabinet of President George W. Bush. Talk about foxes guarding the henhouse! Compared to these folks, naming El Chapo to head the DEA, as suggested in a New Yorker satire by Andy Borowitz, would be a moderate pick.

The future of not only public health, but also your individual private health, now and when you get to retirement age, is in great jeopardy. But, then, so is everything else that helps people. Not to mention the earth, since global warming is likely to accelerate during a Trump administration. There is an endless string of battles before us.

And we must join every one.