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Medicare turns 40 tomorrow. That, of course, is the program that helps the elderly and disabled pay their medical bills. The legislation was decades in the making. The final bill was written in just two days, the result of compromises and expediencies. Many health planners feared it would fall apart, but Medicare has survived. NPR's Joanne Silberner reports on the difficult birth and growing pains of one of the most popular government programs ever.


Ninety-one-year-old Bob Ball probably knows more than anyone still alive about the compromises that went into creating Medicare. He helped write the legislation. It was a giant scale-back from what Ball and others really wanted: national health insurance for everyone. After decades of unsuccessful effort, they decided to focus on just the elderly.

Mr. BOB BALL: It started with the elderly completely for political reasons. It was something we thought we could get.

SILBERNER: Ball admits it doesn't make economic sense.

Mr. BALL: For the amount of money you spend, you get the least amount from the elderly. If they're cured, they have a relatively small life ahead of them. They're very expensive to cover. They have multiple illnesses. They use more hospitalization than anybody else.

SILBERNER: But medical care was beyond the reach of many older people, and when Lyndon Johnson got a mandate in the 1964 presidential election, he put health care on top of his agenda. His focus was on insurance for hospitalizations.

President LYNDON JOHNSON: We must provide hospital insurance for our older citizens, financed by every worker and his employer under Social Security...

(Soundbite of applause)

Pres. JOHNSON: ...to protect him in his old age in a dignified manner.

SILBERNER: The American Medical Association was lobbying strongly against government involvement in medicine. They got Ronald Reagan, then an actor, to speak out against a plan.

Mr. RONALD REAGAN: One of the traditional methods of imposing statism or socialism on a people has been by way of medicine. It's very easy to disguise a medical program as a humanitarian project.

SILBERNER: Johnson and Democrats on Capitol Hill focused on automatic insurance for hospitalizations rather than fighting the doctors. There were two other proposals in Washington. One was an expansion of an existing program for the poor. That was supported by the AMA. The other was voluntary insurance to cover doctors' bills. For months, Robert Ball and others huddled with members of the House Ways and Means Committee, headed by Democratic Representative Wilbur Mills. It looked like it was going to be a long, slow process. And in one day, Mills abruptly suggested they combine all three plans: hospitalization, doctor's bills and a program for the poor. Ball remembers what Mills said very well.

Mr. BALL: `Put all that together. What's wrong with that? Why don't we do that?' And we were astounded. We had spent years in honing the provisions of the hospital insurance program.

SILBERNER: And how long did he give you to write that legislation?

Mr. BALL: Oh, I think, at most, maybe two days.

SILBERNER: Ball says Wilbur Mills didn't want to give the opposition a chance to coalesce, so they stayed up till 3 or 4 each night. They cobbled together bits of the initial bills. They expanded an already existing program into what would become Medicaid for poor people. They met the deadline. A few months of deliberations and minor changes followed, and President Johnson spoke at the signing of the bill on July 30th, 1965.

(Soundbite from July 30th, 1965)

Pres. JOHNSON: No longer will older Americans be denied the healing miracle of modern medicine. No longer will illness crush and destroy the savings that they have so carefully put away over a lifetime so that they might enjoy dignity in their later years.

SILBERNER: Ball knew there was more work to go.

Mr. BALL: Oh, I thought it was going to be very, very hard, and it was very, very hard. Came close to being impossible.

SILBERNER: Nineteen million older people were eligible for Medicare.

Mr. BALL: We had to contact every one of them, to the extent we possibly could, with information on a voluntary plan, and they had to actually sign an application saying, yes, they wanted the coverage or, no, they didn't.

SILBERNER: The Forest Service looked for hermits in the woods. Social Security, which Ball headed, sent out three mailings, and there were big signs on post office trucks. There was a problem with the South. Hospitals couldn't get Medicare money without desegregating. Many didn't want to. The administration solved that one by sending 1,000 inspectors to Southern hospitals. Ball realized even as he was working on the legislation that they couldn't plan for everything. There would be problems; most notably, the lack of price controls.

Mr. BALL: We had the naive idea that if it didn't work well in practice, we could come back and get sensible changes, which doesn't turn out to be quite the case.

SILBERNER: Some cost controls have come in over loud complaints from doctors and hospitals. Brandeis health policy Professor Stuart Altman says the program Ball and others designed has been great, but it has to change.

Professor STUART ALTMAN (Brandeis): There is no way--no way--that Medicare can survive in its current form, given the very clear growth in the population that's going to come online beginning in 2010, 2011, and the continued acceleration in the cost of health care. That's impossible.

SILBERNER: Altman was deputy assistant secretary for health policy in the Nixon administration in 1971. He's been watching Medicare closely ever since.

Prof. ALTMAN: Some combination of more money, tighter fiscal controls, I think are very possible and, in fact, I believe the American people will do it because they really, really like, if not terribly badly need, this program.

SILBERNER: The current head of Medicare, Mark McClellan, spoke yesterday at the National Press Club. He says older people are doing a lot better than in 1965, when only one in four had adequate levels of hospital insurance. He's working on the biggest change ever in Medicare.

Mr. MARK McCLELLAN (Head of Medicare): In the 21st century, helping to pay the doctor and hospital bills isn't enough. Drugs and other preventive treatments account for more and more of what medicine has to offer; yet until recently, Medicare didn't really cover them. Now as Medicare gets to its 40th birthday, we are adding this coverage.

SILBERNER: But the program has proven notoriously difficult to change. A bipartisan commission met in 1998 and 1999 and couldn't agree on a plan. Bob Ball, as both a Medicare planner and now a beneficiary, agrees that some changes are needed, but at least for the last 40 years, the program worked.

Mr. BALL: Medicare has been a tremendous success, for me and I would say for the country, it's--certainly for all the elderly patients and their sons and daughters who would otherwise had to individually pay for it. And I don't know anybody who wants to go back when there wasn't a Medicare plan.

SILBERNER: He's still disappointed, though, that the original plan to extend Medicare to everyone, to have universal health insurance, hasn't panned out. Joanne Silberner, NPR News, Washington.

MONTAGNE: This is NPR News. Transcript provided by NPR, Copyright NPR.

Steve Inskeep is a host of NPR's Morning Edition, as well as NPR's morning news podcast Up First.