When a bullet ended John F. Kennedy's life, Lyndon Johnson wasted no time on talk. He scooped up the fallen president's banner and vigorously pursued an ambitious domestic agenda, including national health insurance for the elderly.
Johnson put his huge shoulder to the wheel and got the job done over the fierce opposition of the American Medical Association and Republican conservatives. Using the legislative skill he gained serving in the U.S. Senate, Kennedy's mantle and the overwhelming mandate he received in the 1964 presidential election, Johnson and his allies engineered the enactment of Medicare the following year.
No chatter and no hesitancy. He stressed the urgent need for Medicare and got the job done.
Three decades later, things have changed for the worse. The program Johnson helped create is facing bankruptcy in four years, and not many of Washington's powerful people seem inclined to charge to the rescue.
To date, there has been little more than talk about what to do. Last year, both President Clinton and campaign rival Bob Dole talked about a bipartisan commission to study the problem. HHS Secretary Donna Shalala talked recently about the possibility of such a panel.
Talk. The suggestions ring a familiar bell. The classic Washington device for avoiding politically risky decisions has long been the study conference. Calling a glamorous group together to examine the problem looks like action. More often than not, however, all that results are volumes of reports, pages of headlines and little else.
A good example of this is the Social Security Council, which recently issued three sets of recommendations from the subgroups that formed along political and economic lines as the council deliberated. The groups split on exactly what to do, although they did endorse the notion of privatizing at least some Social Security money.
The past few years are littered with examples of groups that spent months, even years, and millions of dollars with nothing to show for it but some dead trees. Take the Pepper Commission, which issued a "call to action" that resulted in lots of recommendations but no action. And take President Bush's Medicare commission headed by GOP lobbyist Deborah Steelman. It never even managed to reach any real recommendations. Or the Entitlement Commission headed by Sen. Bob Kerry (D-Neb.) and former Sen. John Danforth (R-Mo.). It also issued a report filled with recommendations that fell on deaf ears. If past is prologue, the next in the series of useless assemblies will be President Clinton's quality commission.
That's because recommendations are just recommendations. They have no force of law behind them. To be something meaningful, they must be examined under the political microscope, translated into legislation and be subject to what promises to be near-endless debate in a divided Congress.
That's not to mention the political jousting between Congress and the White House.
Another study group was assembled in the early 1980s to examine the Medicare solvency problem. The House Ways and Means Committee put together a panel of experts, many of them the same experts who are addressing the same subject today. The experts gushed up volumes of opinions and data and agreed that there was, in fact, a problem that needed fixing. The Ways and Means Committee then seized the report and placed it on a shelf.
Still another example of Washington's proclivity for delaying long-term solutions was provided by the Prospective Payment Assessment Commission, a panel that advises Congress on Medicare issues. The commission recommended that the government freeze fiscal 1998 Medicare hospital inpatient fees. If adopted, the plan could reduce the drain on the trust fund and delay the date on which the fund goes belly up. But the effect would be only temporary.
On rare occasions, a study commission can be valuable. Take the Social Security commission that in 1983 recommended ways to save the program. That panel was headed by Alan Greenspan, now chairman of the Federal Reserve Board, and its suggestions were adopted with comparative dispatch, but only after it became clear that the fund would be bankrupt in a matter of months. According to Health Insurance Association of America President Willis Gradison, who served on the Greenspan commission while a member of the House, the panel had been paralyzed by differences between the members when a report was released that showed the Social Security fund had only months to live. That crisis spurred the group to action, and within weeks it wrote recommendations that Congress quickly adopted.
There is no such recognition of urgency today. Pressures to balance the budget and cut taxes have diverted attention from the problem. The administration has further diminished the sense of dread about Medicare by proposing to shift outpatient care from Part A to Part B, an accounting gimmick that would postpone, but not prevent, the demise of the hospital trust fund.
Responsible and knowledgeable leaders such as Bruce Vladeck, HCFA's administrator, have repeatedly been warning that a long-term solution to Medicare's woes is needed, not just a quick fix. He has called for "a dialogue of real people outside the (Washington) beltway" to help devise a rescue.
What is needed for a true long-term solution to the hospital trust fund's continuing crises is determined action by the president and Congress. If they really want a commission to find solutions to Medicare's woes, they must make a commitment to enact those remedies without delay.
Of course, that requires a strong desire to do something. There was a lot to criticize about Lyndon Johnson, but at least he was a man of action.
Too bad we don't have him now.
Brazda is a Washington-based healthcare journalist.