Bob Ball was certainly not the only mind behind the country's largest public health insurance program.
But as commissioner of the Social Security Administration from 1962 to 1973, Ball played a critical role in creating and implementing Medicare. The program now covers nearly 40 million beneficiaries at a projected cost of about $228 billion for federal fiscal 1999.
Ball was also associated with key improvements to Social Security, including those recommended by the Greenspan Commission in the early 1980s and subsequent changes in the 1990s.
But in healthcare, his primary legacy is as one of the architects of Medicare. Ball helped lawmakers pen the 1965 amendments to the Social Security Act that created Medicare.
His implementation of the program was "a monumental task, which required probably as much management skill as the invasion of Normandy," says Philip Lee, professor emeritus of social medicine at the medical school of the University of California at San Francisco.
As assistant secretary of health in the mid-1960s, Lee worked closely with Ball in the early years of Medicare.
"It's hard for us to realize now what a gaping hole we had," says David Hamburg, president emeritus of Carnegie Corp. in New York. "Medicare was a very important way of providing healthcare to a segment of the population that was badly neglected at the time: the elderly."
Hamburg was president of the Institute of Medicine when Ball became a senior scholar there after leaving the Social Security Administration.
In helping Medicare become a reality, Ball reshaped the landscape of healthcare in the U.S. For instance, Ball directed Medicare to press for the desegregation of most of the nation's white-only hospitals. He insisted on extensive surveying to guarantee that all participating hospitals followed the nondiscrimination policy mandated by the Civil Rights Act of 1964.
Learning from experience. Ball likes to tell the story of his grandfather, who came to live with his family when Ball was a boy. In those days, Ball points out, the Social Security program had yet to be invented. His grandfather tried to keep his sense of independence by paying the young Ball a few dollars a week to help him with day-to-day tasks. That experience, Ball says, left him with a keen sense of the insecurity of old age.
As it turned out, Ball spent a quarter of a century in the Social Security Administration, working to ensure a more secure world for the elderly. Few would contradict what Lee says of him: that he was "one of the great public servants of this century."
Robert M. Ball was born on March 28, 1914, the third child of a Methodist minister. He graduated in 1935 from Wesleyan University in Middletown, Conn., with a bachelor's degree in English and stayed an extra year to complete a master's in economics.
Once he graduated, Ball's first order of business was to marry his sweetheart and set out with $50 and a tent on a two-month honeymoon.
Civil service calling. In 1939, Ball went to work for the Social Security Administration. The agency, created by Congress in 1935, hadn't done much until 1937, when it started issuing Social Security numbers.
Ball moved up steadily in the Social Security ranks, becoming manager of a small New Jersey office, then assistant manager of a larger office. But, Ball says, his career did not really take off until 1942, when he was transferred to the central office.
There, he trained new employees who were sent to work in the district offices. It was a crash course in leadership and the nitty-gritty of the program.
Seven years in government made Ball an expert on Social Security issues. After a stint in a nongovernment job conducting short-term seminars for top administrators of the Social Security program, he joined a Social Security advisory committee established by the Senate Finance Committee in 1948. The committee issued a report that resulted in the 1950 amendments to the Social Security Act. Those amendments increased benefits by 72% and greatly extended coverage.
Ball returned to the Social Security Administration in 1949 as an assistant director of the Bureau of Old Age and Survivor's Insurance. In 1952, he became acting director for a year and deputy director for the next 10 years.
Getting down to business. In 1962, President Kennedy appointed him commissioner of the Social Security Administration. From then on, Ball made it his business to get some kind of national health insurance through Congress.
The decision to focus on covering the elderly, despite the probable higher cost, was strategic. Seniors were "the group we had the best chance with politically," Ball says. Proponents of a new health insurance program needed all the allies they could get, because the American Medical Association had long since declared its vehement opposition to any government involvement in healthcare.
The legislation that would become the hospital reimbursement part of Medicare was honed over a period of years to incorporate the views of the American Hospital Association, the bill sponsors and the Kennedy and Johnson administrations. Throughout, Ball contributed his expertise and his ability to mediate.
"He had an integrating frame of mind, to look at ways that could bring players together," says Hamburg, describing Ball's later work at the Institute of Medicine.
The proposal for the program that would pay doctors' fees-Medicare Part B-was the result of a breakthrough compromise between the AMA lobby, the House Ways and Means Committee and the Johnson administration, and it had to be written quickly.
"Bob Ball and his staff actually drafted it overnight," says Lee.
The "triple-layered cake"-Medicare Part A and Part B, and Medicaid-became law in 1965 as part of the Social Security Act.
Passing Medicare was only the first step. "It is a long way to go from a law written on a piece of paper until it is a going program," Ball says. "The administrative task was enormous," he adds.
Some 19 million people who were 65 or older had to be notified of the program and provided with health insurance cards. The administration also conducted an unprecedented educational effort on Part B, the voluntary program that paid doctors' fees. More than 90% of those eligible signed up for the $3 per month program.
"The post office put up huge billboards on the side of all their trucks about the March 31st deadline for signing up," Ball recalls. "The Forest Services had forest rangers out in the woods looking for hermits to sign up for the voluntary plan."
While Ball oversaw the rest of the SSA's programs, he worked on a day-to-day basis with Arthur Hess, director of the Bureau of Health Insurance, the agency directly in charge of Medicare.
Medicare participation required hospitals to comply with the Civil Rights Act, as well as staffing and other federal mandates. One thousand surveyors fanned out across the country to certify more than 6,000 hospitals by July 1, 1966, the date the new program went into effect.
"In the South there were big problems," says Ball. But the benefits of participation outweighed old prejudices, and the vast majority of hospitals complied by deadline.
The Social Security Administration also had to plan for a possible surge in the demand for beds, as some older people who had not seen a doctor in years suddenly were told they needed to be hospitalized. Contingency plans were put in place: "We had the Army hospitals and the veterans hospitals alerted, and there were plans even to use helicopters to move people," he says.
But as it turned out, "we didn't need a single helicopter."
Given the speed with which Medicare was initially implemented-it took 18 months to get the whole program up and running-Ball says he is disappointed that the pace has since slowed.
"Those of us who were active at the time are still astounded that 30 years after the passage, only the disabled have been added to Medicare," Ball says.
Scholarly pursuits. After leaving the Social Security Administration in 1972, Ball worked as a senior scholar at the Institute of Medicine, spending seven years on Social Security and national health insurance issues.
He has also written several books, including Because We're All in This Together, in which he argues for the expansion of long-term-care insurance.
In 1986, Ball founded the National Academy of Social Insurance to foster networking among professionals in the field and to help educate the public about social insurance programs.
Lee says Ball continues to be an "invaluable source of advice and support" to members of Congress and policy think tanks on health issues ranging from long-term care to child health insurance.
And Ball still seeks wider access to national health insurance, although at a measured pace. "The arguments in favor of national health insurance are as strong as ever," he says. "But it must be done a step at a time."