Will Medicare and Medicaid predict ACA's future?

While politicians debate the future of Medicare and Medicaid, few question that those programs are here to stay. It's easy to forget how controversial the idea of government healthcare programs was for most of the 20th century, and how many decades it took to enact the programs.

Supporters of the Affordable Care Act, which arrived in a more polarized era, hope it will eventually receive similar public acceptance. The history of Medicare and Medicaid offers some reasons to think the ACA will become a fixture of the healthcare landscape—and some to think it won't.

Starting with Theodore Roosevelt in 1912, political progressives, labor union activists and social reformers pushed for a national health insurance system. But after President Harry Truman's 1948 bid for a universal, single-payer plan failed because of opposition from conservatives and organized medicine, supporters focused on expanding coverage for the elderly. They hoped to build on those gains to expand coverage to the rest of the population—never dreaming that their quest would continue well into the 21st century.

For Medicare proponents, starting with coverage for the elderly seemed like smart politics. “Everyone has parents,” noted Dr. David Blumenthal, president of the Commonwealth Fund, who has written about the history of Medicare and Medicaid. Seniors are widely seen as a “morally worthy” population, said Theda Skocpol, a Harvard University government professor who has written about healthcare reform.

Insuring the poor was an afterthought for President Lyndon Johnson, who focused on creating Medicare following the Democrats' landslide election victory in 1964. Indeed, Rep. Wilbur Mills (D-Ark.), the House Ways & Means chairman who led the bill's drafting, included Medicaid coverage for the poor at least partly as a way to blunt future pressure to expand coverage to everyone, which he opposed. When Johnson signed the Medicare and Medicaid legislation on July 30, 1965, he did not mention Medicaid by name, noted Theodore Marmor, a Yale University professor emeritus of public policy.

The political circumstances surrounding passage of the law and the ACA have many similarities. In both cases, a Democratic presidential candidate had campaigned on expanding healthcare and won a big election victory. Each then moved quickly to pass a reform plan. Congressional leaders also played strong roles.

Both President Johnson and President Barack Obama learned from their predecessors' failed healthcare reform attempts. Liberals made major compromises to win passage. Both efforts avoided strict cost controls to avoid stirring up healthcare industry opposition.

But there also were important differences. Unlike the ACA's coverage expansions, there was some GOP support in 1965 for extending coverage to seniors and the poor. Medicare built on the immensely popular Social Security program, and was available to everyone regardless of income.

In 1965, there was still broad public support for government social programs. Labor unions were far more powerful than they are today. By 2009, opposition to government healthcare programs had become much more central to the GOP, which had grown more ideologically conservative, Skocpol said.

For modern-day Republicans, the success of government-led healthcare reform threatens to undermine their core political message. In 1993, GOP strategist William Kristol famously warned that if President Bill Clinton won passage of his healthcare reform legislation, “its success would signal a rebirth of centralized welfare-state policy … and strike a punishing blow against Republican claims to defend the middle class by restraining government.”

“Republicans understand the long-term political stakes better than Democrats,” Skocpol said. “That's why they have fought the ACA tooth and nail.”

One lesson Obama and fellow Democrats failed to learn from Johnson was the importance of getting the program off to a strong, fast start. That Obamacare weakness gave opponents ammunition Medicare's foes never had. Medicare enrolled nearly all seniors within a year of the program's creation and quickly became popular. In contrast, it was four years before the ACA's coverage expansion took full effect, and the launch was rocky.

Nevertheless, observers agree that it's hard to take back government benefits that millions of Americans have come to appreciate and that also help powerful healthcare industry groups. That's what ACA supporters are counting on to give the law the same staying power as Medicare and Medicaid. “Congress doesn't take things away from people,” Blumenthal said.