Forty years old seems to be a time in life when many adults begin to reassess things. They take a hard look at where they've been, where they are, where they want to go and whether they are on the right road to get there. They've amassed a lot of experiences, had some accomplishments and know a lot more than they did when they started. All of this, of course, guides their decisions about the future: Radical change? Stay the course? Something in between?
The 40th anniversary of Medicare and Medicaid should celebrate how important these programs have been to millions of men, women and children over the decades. But it also should signal the start of a new national conversation on just what we want the healthcare future of America to be.
Be certain, these milestone programs will largely pave the road to that future. It has been that way since 1965. If Medicare and Medicaid are to continue their uniquely different missions for another 40 years, then a tough and discerning look at their successes and failures is in order.
Let's remember what President Lyndon B. Johnson said back on July 30, 1965, in Independence, Mo., during the ceremony at which he signed Medicare and Medicaid into law. He was praising President Harry S. Truman, who was on hand and had planted the seed for Medicare 20 years earlier. But Johnson's words also reflected the promise of Medicare and Medicaid: "Many men can make many proposals. Many men can draft many laws. But few have the piercing and humane eye that can see beyond the words to the people that they touch. Few can see past the speeches and the political battles to the doctor over there that is tending the infirm, and to the hospital that is receiving those in anguish, or feel in their heart painful wrath at the injustice which denies the miracle of healing to the old and to the poor."
It is again time to see beyond speeches and politics, and to uphold an American tradition of caring that Johnson said "directs us never to ignore and spurn those who suffer untended in a land of abundance."
In 1965, fewer than half of America's senior citizens had health coverage, and the uninsured had no place to turn. But in that year, our nation took a bold step to expand coverage to the elderly and poor. There is much to celebrate.
Seniors, disabled persons, the working poor-millions of Americans have coverage because of the promise our society made in 1965. The programs have been updated over the years with more preventive services, new payment systems like the prospective payment system, the inclusion of new technologies, and the introduction of prescription-drug coverage.
Life expectancy has been extended and the quality of life has improved for many.
Medicare, combined with Social Security, has largely attained its goal of protecting the elderly from impoverishment, and is currently serving more than 41 million Americans. Medicaid has had a more complicated history. It serves more than 50 million people, including a quarter of all children in the U.S., yet millions of Americans remain uninsured.
Changing Medicaid is on the congressional agenda today, forcing policymakers to face the larger problems of covering the uninsured, long-term-care needs, disease manage- ment and other thorny issues that need thoughtful attention.
And there are financing challenges. For several decades, baby boomers supported the smaller Depression-era and World War II Medicare populations. Now, the baby boomers are approaching retirement and the population working to support them is smaller. Meanwhile, enrollment in Medicaid has grown, largely because many small businesses and self-employed individuals simply cannot afford insurance.
Changes in population, technology and costs threaten the very solvency of the programs. Both Medicare and Medicaid must change dramatically to survive. But what changes? There is very little agreement: Expand private insurance options, and hope that the marketplace will accomplish the changes? Introduce a means test for Medicare, and exclude higher-income seniors? Raise taxes to preserve the universality of the programs?
Only one thing is clear: Whatever we come up with must begin to do what the current systems doesn't do-reward the highest quality and promote incentives to provide the right care, at the right time, in the right setting.
Partisan politics, marginalization and timidity won't get it done. We need an open, bold, and visionary conversation that includes not just talking, but also a lot of listening. We must listen to patients, to communities, to providers, to payers and to everyone with a stake in the future of our nation's health.
It can begin at the grass roots, community by community across America. But ultimately it must have momentum from the highest levels of national leadership to achieve change that all Americans can support.
That's the way to celebrate Medicare and Medicaid-America's tradition of care and compassion.
Richard Davidson is president of the American Hospital Association.