America's landmark government health care programs, Medicare and Medicaid, celebrate their 50th anniversaries on July 30th. (The other key safety net, Social Security, turns 80 in August.) Decades into operation, the future of these plans is still hotly debated in Washington, as policymakers wrangle over needed changes in their finances. Two major reforms are already underway, which I'll address in a moment.
Meanwhile, outside the Beltway, where real people (aka voters) live, there is little debate about the value of these programs. We like our Medicare and Medicaid—a lot. Republicans, independents and Democrats all feel this way, and by big, big majorities.
*Keep Medicare intact. By two-to-one margins, people of all political persuasions favor preserving Medicare in its current form, as opposed to replacing it with vouchers or other forms of premium support.
Among people ages 65 and older, 85% of Republicans, 89% of independents, and 92% of Democrats say Medicare is very important. And roughly 90% of those using Medicare and Medicaid report positive experiences with the programs. While Medicaid was once viewed as health insurance for poor people, any stigma associated with the program has largely disappeared. If people need it, they’ll sign up for it, Kaiser said.
*Improve Medicare's finances. People are concerned about the future of Medicare, and two-thirds of those surveyed support changing the program to make sure it’s around for future generations. Nearly 60% also support raising Medicare premiums for wealthier seniors. There was little support for raising the Medicare eligibility age or general cost increases for all beneficiaries.
By contrast, nearly nine in ten people want to empower Medicare to negotiate with drug companies over their prices, making it the most wisely supported financial reform. This move is expressly forbidden under the 2003 law that created Part D prescription drug insurance.
*Not enough coverage. Kaiser also found that nearly a third of Medicaid beneficiaries and more than 20% of those on Medicare reduced their use of dental, vision, and hearing care because they couldn’t afford them and the items were not covered by the programs.
Reforms on the way
While the public expects Medicare tomorrow to look much like it does today, the Centers for Medicare & Medicaid Services (CMS) has announced major reforms that will change the way healthcare providers are paid for their services. Instead of being reimbursed for based on the number of services or tests conducted, providers will increasingly be paid based on the quality of the work they do and on how well it helps improve patient health.
That policy is likely to include paying physicians to have conversations with patients about how they would want to be treated if they are too ill to express their wishes. Previous plans to encourage end-of-life discussions were derailed in 2009, when Sarah Palin denounced the plan as an effort to set up "death panels." Today, with millions of boomers aging and more patients wanting a say in their own treatment, these policies have broad support.
At the same time, CMS is pushing providers to coordinate care for Medicare patients. Doctors, hospitals and other care providers will be expected to work together, and their compensation eventually will also be determined by patient outcomes and improved health.
Looking 50 years ahead
These reforms, while significant, are modest compared to the vision that Medicare’s creators had for the program 50 years ago. Back in 1965, Medicare was expected to be the first big step toward universal health care. As Jonathan Oberlander and Theodore R. Marmor write a new collection of 50th anniversary essays about the programs:
“They never imagined that, a half-century after its birth, Medicare would look as it does today, with seniors comprising the vast proportion of its enrollees. Medicare, they expected in 1965, would soon expand far past social insurance protection for the elderly and would evolve into a full-scale system of national health insurance for all Americans.”
There are many reasons why this did not come to pass. But perhaps the single most important factor was the Vietnam War, which soaked enormous sums from the federal budget and diverted the attention of Presidents Lyndon Johnson and Richard Nixon away from any serious efforts to expand Medicare as its creators had hoped.
Will Medicare ever grow into the broader health care program its creators envisioned? Today's political gridlock makes that scenario unlikely. Of course, over the next decades, it's possible that a new consensus will emerge that brings about a national health insurance program. But the American people will have to make it a priority. Let's check back in 2065.
Philip Moeller is an expert on retirement, aging, and health. He is co-author of The New York Times bestseller, “Get What’s Yours: The Secrets to Maxing Out Your Social Security,” and is working on a companion book about Medicare. Reach him at firstname.lastname@example.org or @PhilMoeller on Twitter.