From Medicare for All to Medicare for Some

Why didn’t America pass a national health insurance plan that covered all ages, as other Western democracies did after World War II? Before Johnson passed Medicare, both Franklin Delano Roosevelt and Harry Truman supported such a program, but only timidly. They caved to the zealously anti–single payer American Medical Association (AMA) and Southern Democrats who feared desegregation. In 1957, the scope of American health reform narrowed to a program for the elderly: Medicare.

Morally, the case for seniors was obvious. In 1962, Michael Harrington stirred the nation with his book The Other America, which devoted an entire chapter to the elderly: “Loneliness, isolation, and sickness are the afflictions of the aged in every economic class. But for those who are poor, there is an intensification of each of these tragedies: they are more lonely, more isolated, sicker.”

Economically, the case for seniors was equally apparent. In Health Care for Some, Beatrix Hoffman describes the history of America’s unequal health care system, explaining that the failures of the market were glaring when it came to seniors. Seen by the insurance industry as risky (and therefore costly) customers, seniors were dealt high premiums and sudden or outright denials. Many were put in the undignified position of having to ask for charity — or, worse, simply foregoing desperately needed care.

It was clear that if seniors were to gain access to care, the state had to take on the responsibility.

The Coalition That Won Medicare

Harrington’s book deeply moved John F. Kennedy, who made Medicare a central piece of his domestic agenda. Kennedy, unlike his predecessors, actually went to war with organized medicine. He toured the country, speaking to tens of thousands of senior citizens at Medicare rallies organized by the AFL-CIO.

Organized labor was one of the staunchest proponents of Medicare, pouring heavy resources into Congressional pressure campaigns. The most prominent union fighting for universal health care at the time was the United Auto Workers, led by Walter Reuther. Reuther himself debated the president of the AMA on network cable in 1961. The AMA’s propaganda, which included a red-baiting LP recorded by Ronald Reagan, prompted Reuther to joke about the anti-Medicare campaign: “If they put it in bags, it would help your lawns grow better.”

Following Kennedy’s assassination, Johnson made Medicare a central piece of his presidential campaign. He won in a landslide, alongside the most liberal Congress since 1938.

Johnson saw Medicare as inseparable from his civil rights agenda, raising it in the same breath as voting rights on calls with Martin Luther King Jr. King similarly connected these issues, and in a speech rebuking the AMA he delivered an enduring rallying cry: “Of all the inequalities that exist, the injustice in health care is the most shocking and inhuman.”

The Jim Crow hospital system was a deadly one, in which even emergency care was regularly denied on the basis of race. Prematurely discharging patients in need of emergency care is known as “patient dumping,” and still happens today to people who are uninsured (often homeless or undocumented). An Afro American editorial in 1952 blasted the practice for what it was: “This exclusion is another form of lynching by proxy.”

Unlike Social Security, which left out agricultural, domestic, and unwaged workers, Medicare was a universal program. And because Title VI of the Civil Rights Act required federally funded programs to prohibit discrimination, Medicare could be a weapon for fighting both disparities in health outcomes and segregation in hospitals.

Though it required presidential leadership, Medicare was not a gift from on high — it was a concession made after social movements created unignorable crises. The 1960s was an explosive period for militant protest and mass activism. Medicare would never have been won without such a mass movement in the streets. Euthanizing the insurance industry today will be no different.

Beyond Medicare

Medicare is a simple, cost-effective program that keeps millions of people out of poverty and has helped raise the life expectancy of seniors by over four years. It’s a monumental starting point, but we must go beyond it with Medicare for All.

Medicare’s Part B (voluntary physician insurance) includes barriers to care such as premiums, deductibles, and co-pays. It excludes long-term care, dental services, eyeglasses, and hearing aids. These shortcomings resulted in a new market for selling supplemental private insurance plans (e.g., Medigap and Medicare Advantage) that receive generous government subsidies and shrink the insurance pool of Medicare.

This privatization threatens Medicare by shifting it from a single-payer to a multi-payer program, driving up the cost of overhead, co-pays, and deductibles. If this continues, out-of-pocket health expenses for Medicare beneficiaries are projected to take up half of their Social Security income by 2030. This is why Medicare for All advocates don’t want a public option, or mere “access” to care; we want guaranteed health care for everyone, free at the point of service.

Despite its weaknesses, Medicare is one of America’s most beloved social programs. This is because Medicare is a universal program that is not based on charity. Most people use it or know someone who does — and it works well. Medicare’s universality makes it an engine of solidarity, binding large swathes of the population together in a collective project. By covering both the working class and the middle class, Medicare combats the politics of resentment that otherwise fuels the Right’s agenda.

Take Medicaid, in contrast: means-tested and relegated to state-level provision, it has proven far more susceptible to right-wing cuts and work requirements. By holding firm to Medicare’s principle of universality, Medicare for All will improve the lives of all working people, regardless of age, race, gender, or sexual orientation.

Medicare at its best demonstrates the state’s ability to effectively administer public health in the interest of the many, not the few. Decades of neoliberalism has not reduced the size of the state, especially in the case of health care. In fact, public spending on health care is at an all-time high — but much of that money currently subsidizes private insurance. Neoliberalism simply reshaped the state to serve the interests of economic elites. Medicare for All can dispel the anti-state ideology of the Right and change the whole American attitude to social services.

We can’t simply map the class struggle of the past onto that of the present, but a hopeful political climate is emerging thanks to similar ingredients as the ones present during Medicare’s passage. Mass social movements are in the streets defending abortion rights and immigrant rights. Militant teachers are bringing back the strike. Organized labor may not be all-in on Medicare for All, but National Nurses United is leading the charge. Bernie Sanders, who is willing to go to war with the insurance industry, could provide the necessary presidential leadership.

We are in an opening for serious health reform that hasn’t existed since Medicare was signed into law fifty-four years ago. We must revive the universality of Medicare and demand nothing less than Medicare for All.