Kff Health News' 'what The Health?': Happy 60th, Medicare And Medicaid!

The host

Julie Rovner KFF Health News @jrovner @julierovner.bsky.social

Julie Rovner is main Washington analogous and big of KFF Health News' play wellness argumentation news podcast, "What nan Health?" A noted master connected wellness argumentation issues, Julie is nan writer of nan critically praised reference book "Health Care Politics and Policy A to Z," now successful its 3rd edition.

On July 30, 1965, President Lyndon B. Johnson signed landmark authorities creating Medicare and Medicaid. Sixty years later, nan programs correspond a 5th of nan national fund and supply sum to astir 1 successful 4 Americans. In addition, nan measurement Medicare and Medicaid building and salary for aesculapian attraction has group nan modular for nan backstage assemblage arsenic well.

On this week's typical section of KFF Health News' "What nan Health?" podcast, big Julie Rovner interviews 2 experts connected nan history, development, impact, and early of Medicare and Medicaid.

First, Rovner talks pinch Medicare historiographer and University of North Carolina wellness argumentation professor Jonathan Oberlander. Oberlander is nan writer of nan book "The Political Life of Medicare" and a erstwhile editor of nan Journal of Health Care Policy, Politics and Law.

Then, Rovner chats pinch Sara Rosenbaum, professor emerita astatine George Washington University. Rosenbaum has spent astir her full profession moving connected Medicaid argumentation and has helped style cardinal priorities astatine nan national and authorities levels.

[Editor's note: This transcript was generated utilizing some transcription package and a human's ray touch. It has been edited for style and clarity.] 

Julie Rovner: Hello, and invited backmost to this typical section of "What nan Health?" I'm Julie Rovner, main Washington analogous for KFF Health News, and I'm usually joined by immoderate of nan champion and smartest wellness reporters successful Washington. But this week we've sewage thing typical for you. It's an section marking nan 60th day this summertime of Medicare and Medicaid, nan copy authorities wellness programs that person mostly shaped nan measurement nan U.S. pays for and delivers wellness attraction for nan past half-century. To bring america nan story, I sat down pinch 2 of my favourite experts connected nan subject, University of North Carolina professor Jonathan Oberlander and George Washington University's Sara Rosenbaum. Here are my chats, starting pinch Jonathan Oberlander connected Medicare. 

I americium truthful pleased to invited Jonathan Oberlander to nan podcast. He's a professor of societal medicine, professor of wellness argumentation and management, and adjunct professor of governmental subject astatine nan University of North Carolina School of Medicine successful Chapel Hill and 1 of nan nation's starring experts connected Medicare. John, invited to "What nan Health?" 

Jonathan Oberlander: Great to spot you, Julie. 

Rovner: So Medicare, to maine astatine least, remains nan top paradox successful nan paradox that is nan U.S. wellness attraction system. It is astatine erstwhile some truthful celebrated and truthful untouchable that it's considered nan 3rd obstruction of politics, yet astatine its core, it's a painfully out-of-date and meager use that nevertheless threatens to spell bankrupt connected a regular basis. How did we get here? 

Oberlander: Wow. Let's talk astir nan benefits for a minute. And I deliberation 1 of nan things we tin opportunity astir Medicare successful 2025 arsenic we people this 60th day is it still bears nan imprint of Medicare successful 1965. And erstwhile Medicare was designed arsenic a programme — and nan thought really dates backmost to nan early 1950s — it was not seen arsenic a broad benefit. It was intended to salary for nan astir consequential costs of aesculapian care, for acute attraction costs. And truthful erstwhile it was enacted successful 1965, nan benefits were incomplete. 

And nan problem is, arsenic you cognize very well, they haven't been added to each that much. And present we have, each of america know, arsenic we get older, we mostly don't get healthier. I wish it was true, but it's not. And older persons woody pinch each kinds of analyzable aesculapian issues and person a batch of aesculapian needs, and yet Medicare's benefits are very limited, truthful constricted that really a very mini percent of Medicare beneficiaries person only Medicare. Most Medicare beneficiaries person Medicare positive thing else, and that whitethorn beryllium an individual backstage scheme that they purchase, called a Medigap plan, aliases possibly a declining number of group person retiree wellness security that supplements Medicare. Some low-income Medicare beneficiaries person Medicaid arsenic good arsenic Medicare, and they're dual-eligibles. And immoderate Medicare beneficiaries person other benefits done nan Medicare Advantage program, which I'm judge we will person a batch to say. So nan bottommost line, though, is Medicare has grown. What, astir 70 cardinal Americans trust connected Medicare. But nan use package — pinch immoderate intermittent exceptions that are significant, specified arsenic nan summation of outpatient medicine narcotics successful 2006 — really has not kept pace. 

Rovner: So let's spell backmost to nan beginning. What was nan problem that Medicare group retired to solve? 

Oberlander: Well, it was some a substantive problem and a governmental problem. The origins of Medicare are successful nan ashes, nan failure, of nan Truman management proposals for nationalist wellness security during nan mid- and precocious 1940s. And aft they had mislaid repeatedly, wellness reformers decided they needed a caller strategy. So alternatively of nationalist wellness insurance, what coming we would telephone single-payer, a federal-government-run programme for everybody, they trimmed their ambitions down to initially conscionable infirmary insurance, 60 days of infirmary security for aged Social Security beneficiaries. And that was it. And they thought if they conscionable focused connected older Americans, possibly they would tamp down nan contention and nan guidance of nan American Medical Association and charges of socialized medicine, each things that had really thrown a wrench into plans for nationalist wellness insurance. 

It didn't rather activity retired arsenic they thought. It took astir 14 years from nan clip Medicare was projected to enacted, and location was a big, divisive, arguable statement astir Medicare's enactment. But it was fundamentally a solution to that governmental problem of: How do you enact authorities wellness security successful nan United States? You prime a much sympathetic population. Now, location was a substantive problem, which was successful nan 1940s and particularly 1950s, backstage wellness security was increasing successful nan United States for Americans who are working-age. And that maturation of employer-sponsored wellness security really near retired retirees. They were expensive. Commercial insurers didn't want to screen them. And nan uninsured rate, if you tin judge it, for group complete property 65 earlier Medicare was astir 50% — not 15% but five-zero, 50%. And truthful present you had a organization that had much aesculapian needs, was much expensive, and they had little entree to wellness security than younger people. And Medicare was created successful portion to extremity that disparity and springiness them entree to reliable coverage. 

Rovner: So arsenic you mentioned, Medicare was initially conscionable aimed astatine aged Social Security recipients. What were immoderate of nan biggest use and organization changes arsenic nan years went by? 

Oberlander: So successful position of populations, successful 1972, Medicare added sum for persons who person end-stage renal disease. So group who request dialysis, nary matter what nan property — it's a lifesaving exertion — they tin suffice for Medicare. It didn't really make consciousness to adhd it to Medicare. It's conscionable it was there. So they added it to Medicare. And besides a organization we don't talk astir capable about, younger Americans pinch imperishable disabilities who are recipients of Social Security Disability Insurance for a mates of years. They suffice for Medicare arsenic good and are a very important portion of nan Medicare population. Beyond that, Medicare's covered organization has not really changed each that overmuch since nan beginning, which really would beryllium a awesome disappointment to nan architects of Medicare, who thought nan programme would grow to yet screen everybody. 

In position of benefits, nan use package has been remarkably unchangeable for amended and really astir apt for worse, pinch nan objection of, for example, nan summation of outpatient medicine supplier coverage, which came online successful 2006, nan summation of sum for various preventive services specified arsenic mammography and crab screenings. But Medicare still does not screen semipermanent stays successful nursing homes. Many Americans deliberation it does. They will beryllium disappointed to find retired it does not. Medicare does not cover, generally, proceeding aliases imagination aliases dental services. Traditional Medicare tally by nan authorities does not person a headdress connected nan magnitude of money that beneficiaries tin walk successful a twelvemonth connected deductibles and copayments and truthful forth. So really its benefits stay rather limited. 

Rovner: Even to this time we support proceeding astir "Medicare for All," "Medicare for All," "Medicare for All." Why has this ne'er happened? And mightiness it? 

Oberlander: Medicare was ne'er intended conscionable to beryllium for older persons. The original imagination was enact national wellness security for nan elderly, show that it works, past grow it to children next. And that measurement you person group towards nan extremity of life and astatine nan opening of life covered. And aft you do that, transportation retired fundamentally a pincer activity and screen nan rest, nan mediate ages, and bring them into Medicare until it's Medicare for all. 

And truthful that was their aspiration, and it did not hap that way. Some of it has to do pinch nan costs of Medicare and nan unexpectedly precocious costs astatine nan opening of nan Medicare program. And erstwhile Medicare was seen arsenic a fiscal problem, location wasn't a batch of governmental abstraction to grow it. Some of that has to do pinch conscionable history. If you look astatine nan precocious 1960s erstwhile nan Johnson management was considering expanding Medicare to children, which might've changed nan trajectory of Medicaid and really of each of U.S. wellness attraction policy, nan Vietnam War was raging and nan costs were really precocious and they didn't want to adhd nan disbursal of that, truthful they chose not to do it. 

Part of it has to do pinch a displacement successful nan governmental winds. And Medicare was enacted astatine a very wide clip successful American governmental history. And successful nan 1970s, American authorities shifted to nan right, truthful that arguably Jimmy Carter, a Democrat who became president successful 1976, he was arguably much blimpish connected a wellness argumentation than Republican Richard Nixon was, nan president that preceded him. So arsenic American authorities shifted to nan right, nan thought of Medicare for each done this incremental strategy benignant of vanished. And successful fact, Democrats mostly abandoned that, and they went successful a different direction, which yet culminates successful nan Affordable Care Act. They went to building connected Medicaid and building connected backstage insurance. 

What's absorbing is you person seen successful nan past decade this resurgence of "Medicare for All," and of people pushed astir famously by Bernie Sanders successful nan Senate and done his statesmanlike campaigns. And it has a batch of appeal. You look astatine nan nationalist sentiment polls, it really polls beautiful well. I deliberation a batch of that is really an indictment of U.S. wellness attraction and dissatisfaction pinch each kinds of things astir American wellness insurance. But it faces truthful galore obstacles. If it was easy to do, it would've been done already. And liking group opposition, having to raise taxes, which is not easy successful nan United States, allegations of socialized medicine successful a state that has a beardown libertarian focus, dislodging astir 160 cardinal group pinch backstage security and putting them into Medicare — location are conscionable tremendous obstacles to Medicare for All. So I fishy it's going to proceed to beryllium portion of nan debate, but we are a agelong measurement from it. 

Rovner: Medicare is besides nan biggest azygous payer successful nan nation's wellness attraction strategy and for decades has group nan modular for really backstage security covers and pays for wellness care. Is that still nan case? 

Oberlander: It is successful galore ways. Medicare, astatine nan beginning, had very permissive costs policies. It was fundamentally a blank cheque to nan wellness attraction industry, to physicians and hospitals. And not surprisingly, arsenic a result, Medicare's costs ran up really precocious successful its first decade. When you get into nan 1980s, Medicare becomes an innovator successful costs betterment successful nan United States. And successful nan early 1980s, it starts pinch hospitals and adopts what we telephone prospective costs for hospitals successful nan early 1980s, and past a interest schedule for physicians later connected astatine nan extremity of nan decade successful nan 1980s. And Medicare has continued to beryllium an important innovator. It is nan location coming for experiments successful accountable attraction organizations and different innovations that we would word value-based purchasing. 

And really, if you look at, for example, really galore commercialized insurers pay, they usage Medicare's expert interest schedule. Now they don't salary nan aforesaid amount, because they're not arsenic large arsenic Medicare. They don't person nan aforesaid leverage. And successful fact, hospitals connected mean are paid astir doubly arsenic overmuch by commercialized insurers than Medicare and physicians astir 20% to 30%. Commercial insurers usage nan interest schedule that Medicare has, and past they set nan dollar magnitude because they simply don't person nan aforesaid benignant of power that Medicare does. 

Rovner: I was going to opportunity we perceive a batch astir administrative costs for wellness insurance. Medicare really has among nan lowest administrative costs, right? 

Oberlander: Yeah, Medicare is reasonably debased successful administrative costs. And of people administrative costs are 1 of nan reasons American wellness attraction is truthful overmuch much costly than different countries. And if you deliberation astir it, erstwhile you enroll successful Medicare, you're mostly enrolled for nan remainder of your life. And that contrasts pinch backstage insurance. It besides contrasts pinch Medicaid, wherever group move connected and disconnected and it creates each kinds of instability. Medicare is simply a programme that is federally administered, though of people a ample stock of nan programme is now delegated retired to backstage insurers, and that is changing nan complexity of administrative arrangements successful Medicare, among different things. 

Rovner: We should astir apt spell backmost and talk astir really Medicare has truthful galore pieces, A and B and C and D. How did that happen? I mean, I for illustration to opportunity it was not made confusing connected purpose, but it was decidedly made confusing. 

Oberlander: Yeah. So astatine nan beginning, Medicare was created pinch Part A and Part B. Part A really was security for inpatient services and hospitals, Part B for outpatient and expert services. And location were 2 reasons for that. One is they were marrying nan modular and a batch of backstage security astatine nan time. So we had Blue Cross for hospitals and Blue Shield for physicians, and that was conscionable for illustration Medicare Part A and Part B. The different logic is nan original Medicare connection was really conscionable Part A, arsenic we mentioned before, conscionable for infirmary insurance, funded by payroll taxes done nan Social Security system. 

Part B, nan thought that you would person this security that beneficiaries could get for expert services that was going to beryllium funded by paying premiums and wide revenues, that was added very, very precocious successful nan Medicare debate. And truthful it came astatine a different time. So it sewage it added connected arsenic Part B. And past yet we added Part C, which are backstage plans that beneficiaries tin take now, called Medicare Advantage, HMOs [health attraction organizations] and PPOs [preferred supplier organizations], and nan full alphabet soup, arsenic an replacement to accepted Medicare. And past Part D, and Part D is medicine supplier coverage. So I deliberation we whitethorn beryllium moving retired of nan letters. We surely person capable to confuse everybody. 

Rovner: We surely do. So we support proceeding astir really Medicare is going broke. Is that true? And tin it beryllium fixed? And really difficult would it be? 

Oberlander: People person been worried astir Medicare going collapsed since astir 1970. And my accuracy connected this is if you've been worrying astir thing being unsustainable for a half a period and it's still here, you're astir apt worrying astir nan incorrect thing. So nan chances of Medicare virtually ever going collapsed and going distant are, if not zero, arsenic adjacent to zero arsenic you tin get. What this has to do pinch is nan measurement that Medicare is funded. And truthful Medicare Part A, infirmary insurance, is funded almost wholly by what we telephone an earmarked payroll tax, nan payroll taxation that workers and their employers salary conscionable for that. 

Rovner: And it's portion of nan Social Security tax, right? 

Oberlander: And it's portion of nan Social Security taxation that group pay. And each year, nan actuaries from Medicare project: How overmuch money are we taking in? How overmuch do we person successful balances for Part A? And what do nan expenditures look like? And truthful erstwhile you perceive group opportunity nan Medicare spot money is going to go, quote, "bankrupt" successful now it's astir a decade, I think, projected from now, what they really mean to opportunity is: OK, erstwhile we get to 2036, Medicare correct now is not projected to person 100% of nan costs it needs to salary for Part A services. We've had aggregate periods during Medicare's governmental history erstwhile we've gotten down to 7 years, 5 years, 4 years. And Congress has ne'er fto that spot money spell insolvent. Politically, deliberation astir it. If there's 1 point we cognize astir members of Congress, they want to beryllium reelected. There are 70 cardinal group successful Medicare. I'm beautiful judge a bully measurement not to get reelected would beryllium to get to say, I don't know, October successful 2036 correct earlier nan 2036 midterm elections, and say: We're sorry. Medicare is conscionable going to extremity paying. 

So nan bully news is things tin change. Congress tin adopt policies, which they person successful nan past, that widen Medicare's finances and fortify its finances. So I deliberation location is bully logic to beryllium concerned astir really do we stabilize Medicare financing. But successful position of what keeps maine up astatine night, Medicare going bankrupt, I wouldn't fto that fuss me, and I wouldn't fto it fuss you. 

Rovner: So really person nan authorities of Medicare changed complete nan years? I mean, astatine nan opening it was very— it was supported by Democrats and opposed by Republicans, and now it's President [Donald] Trump who says, Thou shalt not touch Medicare. 

Oberlander: There've been immoderate twists and turns. If you look astatine nan ballot connected Medicare enactment successful 1965, it was not nan ballot connected Obamacare successful 2010. There were immoderate Northern Republicans, mean wide Republicans, who voted for it, and blimpish Democrats who voted against it. So it was chiefly a partisan statement but not exclusively a partisan debate. And I would opportunity successful betwixt 1965 and it passed successful 1995, nan authorities of Medicare were consensual. There was a batch of bipartisanship. If you deliberation astir nan costs reforms successful Medicare that we person coming and that style Medicare today, nan prospective costs system, nan Medicare interest schedule, those were sponsored by Republican presidents and supported by bipartisan majorities successful Congress. 

And arsenic you will vividly remember, because I cognize that you covered this, nan biggest use —attempted use — description successful Medicare's history astatine nan clip successful 1988 was sponsored by [President] Ronald Reagan, a blimpish Republican. In 2003, nan description of medicine supplier sum was nether a Republican president, George W. Bush. So nan partisan tides person not flowed successful predictable ways, but I do deliberation it's adjacent to say, since 1995, location has been an erosion of bipartisanship successful Medicare and a existent breakdown. And nan logic I take that twelvemonth arsenic a demarcation constituent is for nan first 3 decades of Medicare's life, it ne'er lived nether a Republican-majority Congress. And successful 1995, aft Republicans swept nan '94 elections that brought [Rep.] Newt Gingrich to nan speakership successful nan House and a Republican mostly successful nan Senate, was nan first clip you had Republicans successful Congress arsenic a mostly governing Medicare, and they pursued eager Medicare betterment plans. And successful nan decades since then, Democrats and Republicans person disagreed very sharply complete Medicare and complete nan early of Medicare. 

Now, Donald Trump has thrown a wrench successful nan authorities successful Medicare, arsenic he has successful galore things, because he is not a accepted Republican successful galore senses, including connected Medicare. And he said explicitly erstwhile he ran for president nan first clip that nan effort by [Rep.] Paul Ryan, who was chair of nan Budget Committee, besides speaker of nan House, to really betterment Medicare and accelerate privatization and make ample cuts successful Medicare, he said it was politically stupid. Why would Republicans want to do that? And truthful he has moved nan Republican Party to a different spot successful Medicare, and you tin spot it successful this fund measure that conscionable passed that did each kinds of things to Medicaid and very small to Medicare. I deliberation nan mobility is whether that Trump effect is going to strengthen past Trump. And truthful erstwhile we get retired to, oh, I don't know, 2029, 2030, what is nan Republican statement successful Congress going to be? Have they really moved successful that direction? Or, peculiarly pinch nan soaring fund deficits, is it going to spell backmost to really a statement betwixt Democrats and Republicans astir nan early of Medicare? 

Rovner: So let's talk astir privatization. Medicare Advantage, nan backstage wellness scheme replacement to accepted Medicare, is now much than half nan program, some successful position of group and successful position of budget. Is this nan early of Medicare? Or will we look backmost successful galore years and spot it arsenic benignant of a impermanent diversion? 

Oberlander: I deliberation it's nan coming and astir apt nan future. The early is ever truthful difficult to predict, Julie, because it's unwritten. But, I mean, this is really a shocking result historically, because what Medicare's architects expected was that nan programme was going to grow authorities wellness security to each Americans, first pinch nan older population, past adding children, past adding everybody. Did not move retired that way. The original aspiration was Medicare for each done immoderate incremental means. Instead, 60 years later, we don't person Medicare for all, but Medicare is mostly privatized. It's a hybrid programme pinch a nationalist and backstage constituent that progressively is dominated by backstage insurance. And nan truth that complete half of Medicare beneficiaries are enrolled successful these backstage plans is simply a stunning improvement historically, by nan measurement pinch tons of implications politically, because that's an important caller governmental unit successful Medicare that you person these ample backstage plans, and it's changed Medicare politics. 

I don't deliberation Medicare Advantage is going anywhere. I deliberation nan mobility is: How large is it going to get? And I'm not judge immoderate of america know. It's been connected a maturation trajectory for a agelong time. And nan mobility is: Given that each nan studies show that Medicare Advantage plans are overpaid, and overpaid by a lot, by nan national authorities and it's losing a batch of money connected Medicare Advantage and it's ne'er saved money, is location going to travel a constituent wherever they really clamp down? There person been immoderate incremental efforts to effort and restrain payments. Really haven't had overmuch effect. Are we really going to get to a spot wherever nan national authorities says: We request savings, yeah. This 22% other that you're getting, no, we can't do that anymore? 

So I deliberation it's an unfastened mobility about: How large is it going to get? Is it going to beryllium two-thirds of nan Medicare program, three-quarters of nan Medicare program? And if so, past what is nan future, turning nan mobility connected its head, of accepted Medicare if it's that small? And that's 1 of nan awesome questions astir Medicare successful nan adjacent decade aliases two. 

Rovner: So for each nan needs that Medicare does salary for, 1 immense spread that remains is its deficiency of sum for semipermanent care, which I deliberation you mentioned astatine nan outset. I wrote my first communicative connected Medicare's deficiency of a semipermanent attraction use successful 1986 erstwhile I was successful my 20s. Now I americium successful my 60s, and we still haven't solved nan semipermanent attraction dilemma. Why has this 1 point been truthful very difficult to address? 

Oberlander: It is nan rumor that will not speak its name. It's specified a immense problem, and we don't talk astir it. And nan measurement we shape and salary for semipermanent attraction successful nan United States is really terrible. The costs of semipermanent attraction successful nursing homes has skyrocketed. It's, arsenic anybody who knows who's had a family personnel woody pinch this, it is perfectly a staggering costs to salary for personification to enactment successful a nursing home. And I think, paradoxically, 1 of nan reasons we don't talk astir it is really because of that cost, because nan budgetary implications of this are truthful precocious that members of Congress and statesmanlike administrations conscionable don't spell there. And what we've done alternatively is we've created a benignant of de facto nonsystem wherever group walk down, often successful not very perfect ways, to suffice for Medicaid. So we've sewage Medicaid arsenic a awesome payer for organization semipermanent care. 

We person expanded location health, semipermanent care, some successful Medicare and Medicaid, and that's a increasing portion of nan system. Private security has ne'er really developed. It's not very stable. The security is costly and difficult for group to spend and often not very good. And I deliberation arsenic nan babe boomers age, of people nan request for semipermanent attraction conscionable keeps increasing and growing, and yet we paid much attraction to it erstwhile you were successful your 20s. Not to day you, but you did it first. I mean, we paid overmuch much attention, I deliberation you would agree, to this rumor connected nan nationalist shape backmost erstwhile [Sen.] Claude Pepper was successful Congress, what, 40 years ago, and it is not really talked astir anymore. We've benignant of swept it up nether nan rug. And nan consequence of that is simply a batch of Americans are near pinch unspeakable situations erstwhile personification needs a semipermanent attraction stay. 

Rovner: And 40 years later, group still don't cognize that Medicare doesn't screen astir semipermanent care. 

Oberlander: And yes, group still don't know. And yeah, they presume that: Medicare, of course, it's a programme for older persons. Of people it must screen semipermanent care. And unluckily it does not. 

Rovner: So 1 different point that Medicare does do that astir group don't recognize is amended astir of nan wellness attraction workforce, surely doctors. People don't recognize nan measurement that Medicare subsidizes nan training of doctors. Is that thing that we're going to person to look astatine going forward? 

Oberlander: Medicare does play a immense domiciled successful subsidizing aesculapian education, and I deliberation — you ask: Is it thing we person to look at? It's thing that of people provides a batch of societal value. I deliberation that nan rumor for Medicare, and not conscionable for postgraduate aesculapian acquisition but for each of Medicare, is this: We person a national fund shortage that was already enormous. We conscionable added to it and added to it a batch successful nan alleged One Big Beautiful Bill. So we person reddish ink arsenic acold arsenic nan oculus tin see. And my prediction, which I don't deliberation takes a batch of courage, is that sooner aliases later, astir apt sooner, members of Congress are going to look up and see: Wait a minute. We person this gargantuan deficit. And they're going to opportunity — it's a shortage that is going to person exploded because of nan taxation cuts — but they're going to say: Oh, look astatine this deficit. We've sewage to tame authorities spending. 

Well, OK. Where does nan authorities walk money? And of course, why did Willie Sutton rob banks? That's wherever nan money was. That's what he famously quipped. Well, wherever does Congress spell for budgetary savings? And this has been existent for 40 years now. They spell to Medicare. So I deliberation location is simply a reckoning coming wherever Congress will look for awesome savings successful Medicare arsenic a consequence of nan broader fiscal image successful nan United States, and that is going to person implications for each parts of Medicare. 

Rovner: So past question. I cognize you don't want to foretell nan future. Is Medicare going to beryllium astir successful different 60 years erstwhile you're fresh for it? 

Oberlander: I'm going to beryllium fresh for Medicare person to six years than 60 years. I won't beryllium astir successful 60 years. Yes, yes. The astir important point to opportunity astir Medicare is that status successful nan United States coming is unimaginable without Medicare. Medicare is simply a cornerstone of wellness security, of status security, successful nan United States. It is perfectly unthinkable that we wouldn't person nan Medicare program. And for each nan problems and challenges that it has, it's besides important astatine nan extremity of nan time to retrieve nan successes it's had and nan captious entree to aesculapian attraction that it's provided. And to deliberation astir what nan world would look for illustration for older Americans and persons who person imperishable disabilities who did not person Medicare, what would hap if Medicare was not there? So I deliberation there's nary mobility that Medicare is going to beryllium present successful 60 years. The mobility is: What shape is Medicare going to take? 

Rovner: Excellent. Jonathan Oberlander, convey you truthful much. 

Oberlander: It was awesome to beryllium pinch you, Julie. 

Rovner: I americium truthful pleased to invited Sara Rosenbaum to nan podcast. Sara is professor emerita of health, law, and argumentation astatine George Washington University, 1 of the, if not the, starring experts connected Medicaid. She's besides nan personification who has taught maine astatine slightest 80% of what I cognize astir nan program. So I americium other thrilled that she's agreed to travel beryllium our guide. Sara, welcome. 

Sara Rosenbaum: Thank you for having me. It's specified a pleasance to beryllium connected nan show. 

Rovner: Let's commencement astatine nan beginning. Medicaid was benignant of an afterthought to Medicare erstwhile they were some created 60 years ago. How did Medicaid travel to be? 

Rosenbaum: Yeah, it's a really absorbing question. This is, of course, nan lore, that Medicaid was an afterthought. If you look astatine nan original enactment — which of people was an outgrowth of an earlier law, nan Kerr-Mills Act, which had been enacted astir 5 years earlier — and you publication nan original statutory language, which we lawyers revel successful doing, you are amazed. This was not specified a large afterthought. I would opportunity that Wilbur Cohen and Wilbur Mills and Lyndon Johnson and everybody other had a bully thought of what they were doing. They knew that they were planting nan seeds for a programme that yet would travel to beryllium nan instauration of wellness security for low-income group crossed nan United States, arsenic good as, of course, circumstantial categories specified arsenic group pinch very terrible disabilities. 

Rovner: Why don't you punctual america what Kerr-Mills was? 

Rosenbaum: Yeah. So Kerr-Mills was an earlier, a limited, national assistance program, very overmuch system nan measurement Medicaid is system today, open-ended grants, but it really focused connected nan elderly. And of people it predated Medicare. And Kerr-Mills benignant of helped make nan lawsuit for Medicare, because it was evident that it was specified a constricted programme successful its reach. It could not do what a cosmopolitan security programme for group who had attained a definite age, and yet besides who go disabled, would do. 

Rovner: So what was nan quality betwixt Medicare and Medicaid expected to beryllium erstwhile they were signed into rule 60 years ago? 

Rosenbaum: Yeah. So Medicaid was very overmuch system successful nan classical style of a authorities grants program. It has come, of course, to beryllium truthful overmuch much than that. But it was a assistance to states, and states would group up authorities plans. This is each connection that has go very acquainted to us. And they would supply aesculapian assistance, arsenic it was called, to definite categories of mediocre people. And nan mentation was that nan programme would commencement pinch these people, but tucked into nan — nan categories were rate use recipients — but tucked successful location were a group of group known arsenic nan medically needy, successful nan early days. 

And nan medically needy, I ever felt, was benignant of nan first seeds of thing overmuch bigger, because nan constituent was that it was a programme for group who were low-income, who couldn't spend their aesculapian care, but didn't get rate welfare. So nan mentation was precisely nan mentation that has carried nan programme for 60 years now. And primitively nan thought was that it would really — and of people this has turned retired to beryllium nan lawsuit — that that would alteration group who had very superior wellness attraction costs for things that Medicare did not screen — nursing location care, location wellness benefits ultimately, those kinds of really big-ticket semipermanent attraction items extracurricular of Medicare, because Medicare was really benignant of for illustration Blue Cross Blue Shield for aged group for illustration me. 

Rovner: You weren't aged astatine nan time, though. 

Rosenbaum: I was not. I was conscionable a kid. But nan programme was meant to replicate what folks had had through, during their moving years. And truthful it was very important and very profound, but limited. 

Rovner: So Medicare's agelong been nan much politically celebrated of nan 2 programs— 

Rosenbaum: Yes. 

Rovner: —primarily because of nan governmental clout of older voters, which is really it was created. How was it that Medicaid became nan programme that grew truthful much? 

Rosenbaum: Well, I judge that Medicaid, and this is I deliberation what Wilbur Cohen understood— 

Rovner: And you mightiness punctual america who Wilbur Cohen was. 

Rosenbaum: Wilbur Cohen was nan brilliant down truthful overmuch of nan early societal use reasoning who benignant of was a span betwixt nan world reasoning astir assistance, nan ineligible reasoning astir assistance. By then, by nan clip Wilbur Cohen was moving his magic successful nan Johnson administration, possibly nan azygous astir important article connected societal use argumentation ever written had been written by Charles Reich, "The New Property." That benignant of spelled retired really Americans had travel to expect thief from nan authorities arsenic a right. So he was nan encephalon trust, nan one-man set down reasoning through, pinch members of Congress, what Medicare and Medicaid would look like. He was really nan architect. 

Rovner: He was nan caput of health, education, and use astatine that point, right? 

Rosenbaum: Yeah. Well, I deliberation he was really nan deputy, but you could beryllium correct. I don't retrieve whether he ever assumed nan apical position aliases whether he successful truth was 2nd successful command. It's worthy checking. But he was nan guy. He knew that what would propel Medicaid guardant is that, dissimilar Medicare, which is tied to a premium structure, Medicare is funded done premium payments, which is great, but premium payments are rather unsocial because they are actuarially based. They are benignant of a very tightly controlled shape of financing, because you're asking — whether it's nan authorities aliases now, of course, backstage insurers that statement pinch nan authorities — you're asking them to return connected a batch of financial risk. And truthful everybody wanted nan — for illustration it was really going to activity that measurement — wanted nan assurance of premium structure. 

Well, Medicaid was not. Medicaid is simply a classical nationalist wellness statute. It's wide revenue. And truthful each clip thing happened that required an involution by nan national authorities wherever wellness attraction was concerned, you could conscionable adhd a fewer pages to nan Medicaid statute and extremity up with, voilà, a fix. So I was very privileged. I began my profession successful nan first decade of Medicaid's existence, soon aft nan first awesome leap had happened erstwhile we created, successful 1972, nan Supplemental Security Income program, for group pinch profound disabilities aliases nan aged who were very, very poor. And that, of course, was accompanied beautiful overmuch by Medicaid. People were entitled to Medicaid. 

And by nan clip I came along, everybody was looking astatine different awesome leap. And that awesome leap, nether nan Carter administration, because of a batch of people's activity on nan way, was children. Interestingly, nan original statute — and this is what I mean erstwhile I say, "You spell done nan statute" — there's each kinds of worldly that tells you wherever everybody knew this point was going. There was nan used-to-be-famous Ribicoff Amendment. Sen. [Abraham] Ribicoff of Connecticut offered an amendment to springiness states nan elasticity to screen low-income children without respect to whether they lived successful families that received rate welfare. And not excessively galore years later, on comes nan Department of Health and Human Services, based astatine HEW, that says, You cognize what? And of people this is measurement earlier nan reproductive wellness authorities of today. Somebody said, You know, if we added an unborn constituent to nan Ribicoff kid option, past you could screen mediocre pregnant women. 

And nan original Ribicoff kid program, therefore, including its the-unborn component, which was regulatory, were incredibly important. But they were tied to rate use assistance, and of people rate use assistance began to descend and descend and descend and sink. And by nan mid-'70s, group said, Well, what if we decoupled this class from rate use backing levels and conscionable fto mediocre children person Medicaid? And location past ensued fundamentally a decade-long effort to adhd mediocre children and pregnant women arsenic groups successful their ain correct to nan Medicaid program. And— 

Rovner: That was erstwhile I started covering it. 

Rosenbaum: Yes. 

Rovner: I was going to opportunity it was almost benignant of a stealth description , because it happened spot by spot by bit. But that was nan strategy. 

Rosenbaum: That was nan strategy. And of people nan designer of that strategy — location were many, galore parents of that strategy — but nan existent leader of that strategy was Congressman Henry Waxman and his bonzer staff, who were truthful brilliant, not only successful reasoning done what they would beryllium capable to get done successful nan House — he was of people a chair of nan [Energy and Commerce] wellness subcommittee astatine that constituent successful nan House — but besides what those of america moving extracurricular of authorities would person to do by measurement of delivering support successful nan Senate. And truthful each twelvemonth became benignant of, astatine nan opening of nan year, a strategy convention pinch nan singular Karen Nelson, who was nan unit head for nan wellness subcommittee. And we would each beryllium and say: OK, this twelvemonth we're going to do X. And truthful we've sewage to information up — this is what you could move successful nan House, and this is what we person to spell information up successful nan Senate, and these are nan extracurricular groups. 

It was, they were astonishing that measurement — I mean, governmental athletes. And their governmental athleticism was utilized to execute this bonzer breakthrough, not conscionable for children but later connected for semipermanent services and supports for nan elderly, for group pinch disabilities. We each person that benignant of astonishing legislative prowess to thank, and they sent nan programme connected its way. So by nan move of nan 21st century, we had a Medicaid programme successful which it was a fixed that low-income children and pregnant women would person coverage. It was a fixed that nan programme was propelled — of course, location were galore different things on nan measurement — but would beryllium a overmuch much robust responder to semipermanent attraction needs, and to adults, to working-age adults, because we recognized parents arsenic a group of group who could beryllium helped. 

So each these seeds were here. And Medicaid had done astonishing different activity successful nan early 21st century, for illustration enabling a consequence to nan catastrophe of New Orleans, because it's a wide gross program, aliases nan World Trade Center attacks, wherever abruptly thousands of group needed wellness insurance. And truthful Medicaid was perpetually nan first responder, whether it was a structural first responder for illustration sum for mediocre group aliases whether it was a first responder to people occurring aliases man-made disasters. And that was nan brilliance of nan early years. 

Rovner: I was going to opportunity also, Medicaid was used, I cognize successful nan past 30 aliases truthful years, to fundamentally springiness states much money during economical downturns. 

Rosenbaum: Absolutely. This is 1 of nan things that everybody was truthful delicate to, that arsenic nan programme was building, building, building, what nan national authorities could — now see, conscionable really overmuch indebtedness nan national authorities tin negociate to activity nether — what nan national authorities could sorb successful nan measurement of spending successful bid to beforehand societal use policy. States, because their economies are very otherwise structured, arsenic are their governmental and ineligible systems, could not. And so, galore times — galore times — preferred financing has been utilized to make it imaginable for states to do each kinds of things. And look, we could spell backmost to Sen. Russell Long, not precisely a civilian authorities icon, who was nan begetter of Medicaid's bonzer family readying benefit, who made sure, on pinch Sen. [Herman] Talmadge, who likewise was not precisely a civilian authorities pioneer— 

Rovner: Couple of Southerners. 

Rosenbaum: Yes. That nan family readying use not only would beryllium expansive but would beryllium paid to nan states astatine 90% national financing. So this thought goes each nan measurement backmost to nan early years, and you're perfectly correct that nan financing has been utilized to make it imaginable for states to do things, to make it imaginable for states to support their programs during downturns, correct up done nan covid pandemic, of course. And that's been a tremendously important portion of nan story, conscionable for illustration Medicaid has been utilized to support nan wellness attraction information net, some hospitals done its disproportionate-share infirmary costs program, its different elements that springiness states nan expertise to money their nationalist wellness systems, county-operated nationalist wellness systems, done Medicaid, and of people 1 of nan astir absorbing stories of all, which is nan grade to which Medicaid virtually took a fewer twelve experimental clinics from nan Great Society years that were struggling to past — location were a fewer 100 by nan clip it happened — and created nan financing strategy that coming has created organization wellness centers which service 32 cardinal people. So, I mean, Medicaid is nan powerhouse. It is nan powerhouse. 

Rovner: Today we deliberation of Medicaid, arsenic you were saying, successful position of this awesome organization — seniors successful nursing homes, low-income moms and kids, group pinch disabilities. But Medicaid's besides go nan nation's starring supplier of things for illustration supplier curen and rehabilitation and intelligence wellness care. How overmuch has that been overlooked successful nan modern Medicaid discussions? 

Rosenbaum: Well, I deliberation each of these things thin to get overlooked until they're threatened, right? So each of a sudden, for nan past six months, everybody's had a 101 into what Medicaid does, because each fewer years we find we spell done nan aforesaid thing. This twelvemonth was tougher than immoderate we've faced before. But I put each of Medicaid's contributions to intelligence wellness and addiction curen successful nan class of semipermanent services and supports that Medicaid, because of its financing structure, has been capable to fundamentally wrap astir of a terribly deficient backstage security strategy and Medicare strategy that conscionable do not, they're not system to money these things. Somebody's sewage to money these things. And Medicaid has stepped up each time. And that's why I deliberation nan conflict complete Medicaid that we person each been surviving done since January of this twelvemonth is truthful profound, because nan achievements of nan programme benignant of scope into everything — chronic health, nationalist health, security coverage. I ever tried to explicate to my students that location was nary 1 point that Medicaid does. You can't conscionable picture Medicaid arsenic insurance. It's measurement much than that. So you are perfectly correct to constituent this out. 

Rovner: I consciousness for illustration successful 2017 successful nan conflict complete nan repeal of nan Affordable Care Act, that was benignant of a large alteration for Medicaid. I deliberation group had yet realized that Medicaid had grown larger than Medicare, that it was not conscionable a programme for nan poorest of nan poor, that it did each of these different things that you're talking about, and that really a batch of, I guess, nan stigma had been taken away. And yet this Congress felt comfortable — I don't cognize if I'd opportunity "comfortable" — but a mostly of them voted to make these really deep, profound changes. I mean, what is that going to mean going guardant some to nan wellness attraction strategy and to nan governmental system? 

Rosenbaum: Well, I've spent a batch of clip reasoning successful nan post-enactment play about: When was nan dice cast? When was nan dice formed that group everybody spinning? And I deliberation they, legislature leaders and nan White House leadership, understood nan fatal correction they'd made successful 2017, which was separating nan taxation reforms from nan spending reforms, because of people we were past capable to conflict nan spending reforms connected our ain turf, right? Here, because of nan determination that was made back, I'm sure, almost a twelvemonth ago— 

Rovner: Literally nan thought to do 1 "big, beautiful" bill. 

Rosenbaum: Yes. And that meant that Medicaid, on pinch nutrient stamps, aliases SNAP [the Supplemental Nutrition Assistance Program], on pinch everything else, conscionable became pay-fors. They conscionable became offsets. And nan sanction of nan crippled past became beating backmost each effort to deprive Congress of pay-fors to do nan point that it really wanted to do, which was taxation reform. And truthful we were each reduced to — "we" successful nan consciousness of group who worked connected societal use policy, including a batch of my friends who activity connected taxation argumentation but arsenic a societal use interest — we were each reduced to bystanders successful this effort to get to a trillion dollars. 

Rovner: A trillion dollars successful cuts. 

Rosenbaum: A trillion dollars successful cuts. And truthful it opened nan doorway to bonzer things. I mean, for example, if I could return conscionable a 2nd connected it, connected nan activity requirements. The experiments from Arkansas and New Hampshire and different states, that formed nan ground for truthful overmuch of nan guidance to activity requirements, were very destructive. But nan measurement they worked was group who were connected Medicaid would past person to study successful if they were working, which was not good, because they couldn't navigate nan reddish portion and fell off. But nan exemplary that has been passed, that's been enacted, is for illustration dropping a hydrogen bomb, because you will nary longer beryllium capable to enroll successful Medicaid if you cannot navigate nan reddish tape. And truthful galore of america kept pointing retired that this was a unspeakable thought successful immoderate event, but to enforce this astatine nan constituent of enrollment meant that you were not conscionable simply destabilizing sum for group who had it, you were preventing group from getting it. 

And nan measurement nan statute is written, virtually each personification connected Medicaid coming who's an affected person, nan working-age adults successful description states, is going to person to reapply for nan benefits. It is huge. Huge. And because you can't person Medicaid astatine nan constituent of enrollment unless you could meet these requirements. And truthful I had many, galore disputes on nan measurement pinch group who thought it would beryllium 3 cardinal aliases 4 cardinal aliases 5 cardinal group losing their coverage. It's perchance 20 cardinal people, 20-plus million, nan description population, because while location are exemptions, you're going to person to beryllium an exemption. And immoderate of nan exemptions will beryllium easier than others. But interestingly, nan measurement Medicaid useful successful description states, group conscionable enroll arsenic low-income people. 

So whether you're a parent, whether you person a disablement and you're waiting for Social Security to make nan determination and you're benignant of connected arsenic a mediocre personification while that's happening, it doesn't show up. What shows up is you're a low-income person. And you're going to beryllium confronted pinch having to beryllium your worthy to get wellness care. And erstwhile we tried to face this, we were told rather bluntly that group were told: No, no, it's nan enrollment that's going to region everybody. That's wherever nan savings travel from. And truthful it mislaid each of its humanity, and I deliberation it drove location to maine nan constituent that this was each astir nan money and that's why they were capable to succeed. 

Rovner: So obviously, I mean, I cognize a large root of enrollment for Medicaid is wellness attraction providers themselves. People show up, they're uninsured, and there's personification smart location who says, Hey, you're eligible for Medicaid, truthful we tin get paid. This is going to person a immense effect connected nan supplier community, isn't it?” 

Rosenbaum: Yes. And those providers that have, say, acquisition successful trying to thief their patients enroll successful aliases support their sum will struggle mightily, because they're losing immense amounts of revenue. We did a mates of speedy analyses of conscionable really overmuch money, for example, organization wellness centers stood to lose, and it's complete a five-to-seven-year period. It's successful nan tens of billions of dollars. A friend of excavation successful Georgia told maine that they're astir to laic disconnected their full — this is, We're not affecting children, we were told. They're astir to laic disconnected their full kid outreach staff, who thief families pinch children each complete Georgia enroll successful and support their sum — for nan children. And truthful they can't spend them anymore. 

Rovner: So what happens next? Does this happen? And if it happens, does it return retired nan underpinnings of nan full wellness attraction system? Or does Congress yet recognize what it's done and alteration its mind? 

Rosenbaum: Well, yeah, I mean, I deliberation group are saying, Well, nan two-year runway. It's for illustration 2 years until it becomes effective. The two-year runway is going to benignant of make group hide astir this, and then, boom, it'll beryllium upon us. I don't deliberation so. I deliberation nan two-year runway will extremity up sparkling a immense ray connected nan truth that states cannot instrumentality nan full system. I mean, while we are very focused connected nan number of group who will suffer their coverage, nan states are confronting an insurmountable problem here. They've ne'er had to nexus Medicaid to activity records. And Congress did everything it could to make matters truthful overmuch worse. For example, they could person conscionable said that: We're going to import nan aforesaid requirements that use to SNAP to Medicaid. And truthful if you're getting SNAP successful your moving age, past you automatically enroll successful Medicaid. They didn't do that. They didn't do that. It's a different-enough group of eligibility criteria and exemption categories. For example, SNAP ends, I think, astatine astir 60, and nan Medicaid activity requirements spell each nan measurement to 65. 

Rovner: Age 60 and 65. Yeah. 

Rosenbaum: Yes, exactly. But I mean, nan exemptions are different. The requirements are different. And truthful group are talking about, Oh, we'll conscionable align reporting systems. No, no, no, no. You are liable for each kinds of correction complaint penalties. If you conscionable trust connected SNAP, you can't. So states person nary measurement to woody pinch this, wellness attraction providers that will beryllium called upon to virtually supply nan documentation. My conjecture is that Russell Vought, nan caput of OMB [the Office of Management and Budget], who is really nan personification successful complaint of implementing each of this, is not going to return attestations arsenic evidence. They're going to require documentary grounds and files astir wellness exemptions and continuing wellness exemptions. This is each conscionable to get immoderate wellness care. It's not for illustration you tin eat pinch your Medicaid paper aliases salary your rent pinch your Medicaid card. 

So nan astonishingness, I don't deliberation that's a word, but nan astonishingness of this all, I think, is only going to build and build. And of people truthful overmuch attraction was paid to agrarian hospitals, and truthful they tucked successful this small teeny-tiny agrarian infirmary program. And rather frankly — I conscionable did a post pinch my workfellow Anne Reid astir this astatine HealthAffairs — if you publication nan good people — and Carole Johnson has an fantabulous one — if you publication nan good people — we're not truthful good people — if you publication nan people of nan statute, we noted that offsetting mislaid gross is only 1 of 15 different activities. In fact, you can't conscionable spell to nan authorities and say, you can't spell to Russell Vought and say, Please springiness america our allotment truthful that we tin offset, nan measurement nan money worked backmost during covid. You person to walk your money. My favourite is that you person to walk your money connected things for illustration consultants to thief you creation costs betterment strategies, costs betterment strategies for group who are nary longer injured. So there's nary mitigation strategy for this, and I deliberation nan dream is that Congress will telephone it back 

Rovner: If it doesn't, is this, I mean, nan 1 benignant of metallic lining that I'd been benignant of reasoning astir is, well, possibly if we tear down nan wellness attraction strategy we'll person to commencement again and build a amended one. Is it imaginable that we could get there? Or are we conscionable going to limp along? 

Rosenbaum: I person those thoughts often, and past I extremity and think, well, those of america pinch wellness security could beryllium location and say, Yeah, possibly we conscionable tear down nan wellness strategy to commencement again. Meanwhile, of course, we will person millions of group without wellness care. So interestingly, nan Affordable Care Act, of course, was designed not to tear down nan wellness attraction strategy but to fortify nan wellness attraction system. But it was nan brilliance of nan Affordable Care Act was that it saw nan holes and it benignant of tried to hole them. And if we'd near it alone, pinch everybody successful this, what I see to be, benignant of an intermediate arrangement, we could person done precisely what you are talking about, pinch conscionable astir everybody successful nan United States covered. We could person begun to really do nan superior activity of moving to thing much unified, better, and of people cheaper and much efficient. That's correct — acold easier to use. But we person decided alternatively to tear nan Affordable Care Act apart, some nan entree to nan marketplace by rolling backmost nan assistance and of people nan Medicaid reforms. 

Rovner: Well, happy birthday, Medicaid. 

Rosenbaum: Happy birthday, Medicaid. Today's nan day. 

Rovner: I know. 

Rosenbaum: Yeah. 

Rovner: Thank you truthful much, Sara Rosenbaum. 

Rosenbaum: Thank you for having me. It was a — it was some uplifting and sad. 

Rovner: OK. That's this week's show. I dream you enjoyed it. Thanks arsenic ever to our editor, Emmarie Huetteman, and our producer-engineer, Francis Ying. If you bask nan podcast, you tin subscribe wherever you get your podcasts. We'd admit it if you near america a review. That helps different group find us, too. Also, arsenic always, you tin email america your comments aliases questions. We're astatine [email protected]. Or you tin find maine connected X, @jrovner, aliases connected Bluesky, @julierovner. We're going to return a short break to fto our hardworking unit person immoderate rest. We'll beryllium backmost successful your provender nan Thursday aft Labor Day. Until then, beryllium healthy. 

Credits

• Francis Ying Audio producer
• Emmarie Huetteman Editor