tv Medicaid and Medicare Since the 1960s CSPAN February 8, 2020 3:35pm-3:56pm EST
>> up next, a postdoctoral research associate at princeton university explores the history of medicaid and medicare in the united states, explaining how discussions on universal health care have evolved since the 1960's. this interview was recorded at the annual american historical association meeting. host: george aumoithe is joining us from our studios in new york. thanks for being with us on american history tv.
guest: thanks for having me. host: you have devoted a considerable amount of time studying medicare and medicaid. take us back to that time period and how this legislation was significant at the time and how it has evolved over the last 50-plus years. guest: that's a great question to start off with. medicare and medicaid passed in july 1965. medicaid was really an afterthought in the legislative drafting process. the law's ratification shortly after the assassination of president john f. kennedy meant that there was a greater focus on the medicare law and there were certain historical reasons for this. medicare grew out of the act in 1960 which also grew out of the medical aid for the aged mma program, which was a new deal era program that began in the 1940's and 1950's.
and for that reason, most policymakers and legislators were focused on delivering medical assistance, public insurance options, for the elderly who were at risk of bankruptcy and high costs from end-of-life care. so when medicaid was appended to the law, it was seen as a way to extend a similar program to those who were deemed medically indigent. at first, the category of medical indigence was seen as a way to capture people that did not have incomes below the official poverty line. so say if a family of four in new york made $6,000, if they made $6,001, they would not have qualified for the prior systems. -- assistance. expanded a similar aid for those not below the poverty
line. certainly very different in the 1940's, 1950's, and 1960's from today. if you were in the category that didn't have insurance, what did the elderly do? what were their options? guest: this was the age of charity pair. hospitals weren't necessarily seen as the sites for high-tech care. if you were well-to-do at the turn of the 20th century and had sufficient income, bedside manner was still the predominant mode of delivering care. but it was after the technological advances of the early 20th century, the introduction of antibiotics and innovations in surgery that made hospitals much more attractive. from the get-go, hospitals were built around charity care. elderly folks who could not afford that care oftentimes relied on religious organizations. it's why we still have an extensive network of catholic,
jewish, and other religious hospitals that provide care. similarly, a lot of elderly people would rely on mutual aid organizations. oftentimes organized around ethnic affiliation, whether polish or italian, and these organizations would be able to gather funds to pay for the medical care of the elderly. but if you didn't have access to a charity care hospital or mutual aid association, or if there wasn't some kind of state-based program to provide that care, the elderly basically went without it. this was a particularly pressing problem that johnson saw in his time as a representative in texas. he saw elderly folks going into poverty, going into debt, or withholding or forgoing medical
care. and he really saw that population as a centerpiece for health care reform. the state of public hospitals, especially in large cities like washington, new york, philadelphia, boston, miami. guest: public hospitals were part of this transformation. if the hospital system did not have high-technology or efficacious medical care, it became more so by the mid-20th century. and this attracted municipalities to take on much more of a social welfare function in providing that care. in the case of new york city, there was a department of hospitals that preceded what is today's health and hospitals corporation. and that department of hospitals organized a variety of charity hospitals that were loosely affiliated and did not have centralized control. but what new york city did in 1969 was consolidate the
budgetary process for these hospitals and bring them under one aegis. and new york is quite unique in that regard. in 1969, new york controlled over 50% of the nation's public hospitals. when i cite that stat, a lot of people look askance and say that sounds a little too high for one place. but mind you, it's because public hospitals, municipal hospitals, were not the norm. catholic or charity care hospitals were. when new york consolidated the system, it brought to the fore a municipal hospital system that outmatched many other cities in terms of size and scope. host: does that explain why new york had probably half of the public hospitals if not more in the country when you compare to other large cities like chicago or los angeles? guest: exactly. before the health and hospitals
corporation, the department of hospitals created a coordinating body for charity hospitals. in 1969, thending whole system became fully municipal. another important change was taking the budgetary appropriations process out of the city council and placing it into a quasi-public not-for-profit organization. the thought process being that getting the budgetary process out of the parochial squabbling of city council persons would improve the efficiency of the organization. but history shows that wasn't quite as successful as it was intended. host: if you could, explain the debate in this country and on capitol hill. as you know, 10 years after president obama signed the act, we areare still debating obamacare.
how significant was the assassination of john kennedy in pushing this legislation by president johnson and what was it like on capitol hill? guest: that's a great question. i see the present political circumstances as almost a return or patterning of history because when you look at the passage of medicaid and the resistance of southern states to expand medicaid under the category of medical indigence, you see a lot of rationales or concerns from southern states who are conservative governments in the south today. at the time, people were really concerned about cost-sharing and the debate between liberals and conservatives also became a debate within liberalism itself. a debate between incremental or gradual reform or a push toward universal health care. the debate itself was constrained by a wider national political economy. i look at in my research a series of rich transcripts from the medicaid hearings in 1968.
and in the new york city hearings, there is a really interesting debate between republican governor nelson rockefeller and democratic senator jacob javits. it's actually the republican who advocated for a more expansive, radical change to the health care system toward universal health. senator javits understanding the senate and the national political economy and the constraints therein advocated a more incremental approach. at his right flank was russell b. long who proposed cutting the medical indigence category to become more like the official poverty line and making it more like a welfare medicine program. at 1965search, i look and 1967. 1967 was the year an amendment was passed to make medicare more
firmly a welfare program. you see a more liberal requirement in more liberal states like new york, minnesota, california, massachusetts running up against more conservative states like louisiana, alabama, and other states in the south who wanted to keep a very constrained category for medicaid eligibility and didn't want to necessarily be funding more expansive programs. host: staying with that timeline, you had a number of conservative presidents. nixon, ford, carter. you had high inflation and high unemployment rate in the 1970's. as this was rolling out across the country, what was happening politically in the country? guest: it's very important that you mention rising inflation because this was a signal moment that i see as hobbling the more expansive aims. that law in 1965, senators and
legislators didn't think medicaid would surpass medicare. but it quickly becomes a popular program, at least in the states that wanted to fund it, because of its cost-sharing structure. in new york's case when the laws passed, they used medical indigence standard which was more liberal to expand access to 1.5 million new yorkers. when dixiecrats in southern states pushed back against that law and expansion, the result of restricting medical indigencey meant that million new yorkers 1.5 were taken off the rolls. the johnson era and the great society was seen as an era of excessive liberalism even though it wasn't necessarily purely focused on expanding equity. and so with richard nixon, he
begins to pull back a number of demonstration projects like the regional medical program and the health clinics. he also begins to deemphasize the focus on inpatient care in favor of outpatient care. as inflation intensifies in the 70's, 1973 being the opec oil crisis and the nixon shock where the direct convertibility of the dollar to gold is canceled, a number of macroeconomic shocks push the wider political and national context away from medicaid and this culminates in the administration of a democratic president, jimmy carter, who had to grapple with a second wave of hyperinflation and 1979. and this led carter to push for hospital cost containment legislation that the chamber of
commerce and a group called washington business group for health pushed back against. they called for voluntary rather than mandatory inflation targets. both pieces of carter legislation failed. but it showed how the end of the 1970's, this focus on cost versus equity became a bipartisan consensus. host: as you look at the overall federal budget those are the big , drivers of the federal budget. what was it back in the 1960's and do you see this trajectory , continuing into the future? 1960's, an before the number of health service administration scholars and policy experts began to see a slight uptick in medical inflation but it was not as egregious as the 1970's. this early awareness was part of the impetus of trying to rationalize medical care. nonetheless, by the 1970's, it
becomes very clear that medicaid and medicare had some role in increasing health care costs by bringing more people into the system. especially people who prior did not have care. as you know, there is a slight uptick in costs when you bring did notho are sick or have prior exposure to the medical care system into the system. the program did successively expand and has continued to expand through the years. and even as nixon looked for and triedo programs to deemphasize inpatient care. you see him expand medicaid. but it becomes expansion under categorical means. nixon oversees an expansion of the law to include funding for people suffering from kidney and
renal disease, so there's a kidney dialysis category added in 1972. the history of medicaid in the 1980's becomes a progressive addition of other protected groups. instead of having a wide category under income it becomes , about status. pregnant women are added in the 1980's. the s chip program is added in the 1990's to address children's medical care. you see a slow progressive expansion under the categories. or the affordable care act, you see a return to the medical indigencey moniker . but instead of medical indigencey, it's framed as a
sort of lower middle-class entitlement. the structure of the law is the same. host: why did you select this particular area as part of your research at princeton? guest: my research began by looking at the history of the hiv-aids epidemic. that's a relatively recent history, and it is still current problem. but a lot of the scholarship focuses on the social, activist history or the interpersonal bias between americans. and i was kind of understanding that history but also a little unsatisfied as to how it explained the sort of structural resources at hand to handle the epidemic. i really wanted to reach back in time, back to medicaid and medicare which was just 15 years , before the epidemic to think about how this first national really truly nationwide program changed the health care structure in ways that deemphasize inpatient care and
palliative care and increased the burdens of health care on persons who received outpatient care and returned to their homes to recover or who relied on meager subsidies for pharmaceuticals. i found the reason why the health care system was so inadequately built to meet the aids epidemic. those transformations were taking place in the 1970's. it was really important for me to push back into time to give a prehistory of the aids epidemic but also a prehistory of u.s. health in the latter 20th century. i see those roots as coming out of the new deal and the great society. host: george aumoithe, thank you for joining us. guest: thank you for having me,
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