The Healthcare Revolution
A reflection on Medicaid's history on its 59th birthday.
“In this town, and a thousand other towns like it, there are men and women in pain who will now find ease. There are those, alone in suffering who will now hear the sound of some approaching footsteps coming to help. There are those fearing the terrible darkness of despairing poverty--despite their long years of labor and expectation--who will now look up to see the light of hope and realization.
There just can be no satisfaction, nor any act of leadership, that gives greater satisfaction than this.” Lyndon Johnson July 30, 1965.1
On July 30th, 1965, President Lyndon Johnson invited the press to join him and former president Harry Truman in Independence, Missouri. The occasion? Johnson was going to sign the Social Security Act of 1965. Part of the president’s quest to implement his vision for a “great society,” the bill authorized the establishment of two medical insurance programs: Medicare, which provides health coverage to the elderly and disabled; and Medicaid, which covers indigent children and adults. As he sat next to former President Harry Truman, Johnson commented not only on the importance of the legislation, but the long road it took to make it a reality: “the need for this action is plain; and it is so clear indeed that we marvel not simply at the passage of this bill, but what we marvel at is that it took so many years to pass it.”
Johnson wasn’t wrong. The demands for nationally provided health insurance had been building for decades. During the Great Depression in the 1930s, progressives pushed President Roosevelt to consider legislation providing Americans with coverage, however the powerful political lobby of the American Medical Association (AMA) thwarted those efforts by spending millions of dollars vilifying any government-sponsored insurance program as akin to socialism. While the official start of the Cold War was still a few years away, “socialism” as a concept and a system was not exactly popular in the United States and the AMA’s tactics worked as politicians became weary of supporting anything that resembled socialism, no matter what benefits it might have for their constituents.2
This did not stop Roosevelt’s successor from trying to overcome the AMA and implement a national program. Only a few months into his presidency in 1945, President Harry Truman announced his vision for universal health insurance, which included asking Americans to contribute financially to cover the costs of coverage and quickly turned into an expansion of the Social Security Act. Unfortunately for Truman, the AMA proved to be a stronger foe than he anticipated. The association’s lobbying efforts were once again successful in painting Truman’s proposal as “socialized medicine” and for the first time the AMA suggested that medical coverage come through private insurance.3
It took more than twenty years, and lots of creative politics, for Johnson to achieve his goal. Given the failures of previous administrations, Medicare was considered a significant political risk so Johnson rallied his allies to focus all of their attention and resources on ensuring its passage. This left very little room for anyone to focus on the other, and at the time smaller, program: Medicaid. As a result, Medicaid prompted no political fights and quietly operated in the shadows for years. Even during the welfare reform debates of the early 1990s, most Americans and politicians zeroed in on the cash payments issued under the Aid to Families with Dependent Children (AFDC) program as President Clinton campaigned to “end welfare as we know it.”4 Thus, Medicaid continued to operate largely unnoticed for another decade until President Barack Obama signed the Patient Protection and Affordable Care Act on March 23, 2010.
Suddenly, Medicaid was thrust into the national spotlight where pundits and politicians debated the merits of the bill and more than a few threatened to repeal the legislation. Like Johnson, President Obama threw all of his resources and clout into securing the bill’s passage. Although not as experienced as LBJ, President Obama still managed to push through the gargantuan bill, which expanded Medicaid and instituted a public-private partnership where Americans received tax credits by purchasing health insurance through an online exchange. Aided by the expansion efforts, Medicaid has eclipsed Medicare in terms of membership. As of 2023, over 65 million Americans were enrolled in Medicare and nearly 93 million were on Medicaid. While the ACA, and by extension Medicaid, remains a hot button political issue there is no denying the impact its had on millions of Americans who experienced relief in being able to access medical care without the fear of financial ruin. It remains to be seen what the future holds for Medicaid, but whatever its future, its history remains one for the books.5
On my bookshelf…
Are you a history lover if you do not have a mound of books waiting for you? Between wrapping up my graduate program and getting back into the groove of the podcast, I have several neglected titles waiting for me, but I am making slow (but steady) progress.
I am currently at the beginning of Ron Chernow’s behemoth of a biography, Grant. I just wrapped The Families Civil War: Black Soldiers and the Fight for Racial Justice by Holly A. Pinheiro Jr. which covers the struggle of Black Americans who enlisted during the Civil War. As I am still covering the Civil War, I also just finished Jon Meacham’s And There Was Light which covers the life and legacy of Abraham Lincoln. I am looking forward to starting Ferguson M. Bordewich’s Klan War: Ulysses S. Grant and the Battle to Save Reconstruction as I prepare to launch the next set of episodes for the podcast dedicated to Reconstruction.
On the Podcast…
In June, I welcomed esteemed historian and Harvard professor of history Dr. Robin Bernstein to discuss her latest book, Freeman’s Challenge: The Murder That Shook America’s Original Prison For Profit. Her book is an insightful investigation into the origins of what she describes as penal capitalism and it offers a fresh perspective on the origins of our modern prison system. I definitely recommend taking a listen if you haven’t yet - and of course, picking up a copy of her book.6
Looking ahead on the pod, I am still knee-deep in the Civil War. In July, I’ll be circling back to President Abraham Lincoln and look at some of legacies of the war (I published an introductory episode about the 16th president at the start of my Civil War coverage back in December, you can find that here). I think our time with the Civil War may be coming to an end, but don’t forget you can always request a topic through my website or through any of the social channels. I always enjoy putting together listener requests - you all make me a smarter, better historian.
August will mark the fourth anniversary of Civics & Coffee! I hope to do something a little special in celebration, so keep your eyes out on the various social media spaces for details.
Until then, I look forward to enjoying our weekly cups of coffee together.
All the best,
Alycia
Lyndon B. Johnson, Remarks With President Truman at the Signing in Independence of the Medicare Bill Online by Gerhard Peters and John T. Woolley, The American Presidency Project https://www.presidency.ucsb.edu/node/241296
Laura Katz Olson, The Politics of Medicaid, (New York: Columbia University Press, 2010).
Howard Markel, “69 years ago, a president pitches his idea for national health care,” PBS News Hour, November 19, 2014 https://www.pbs.org/newshour/health/november-19-1945-harry-truman-calls-national-health-insurance-program
William J. Clinton, Address Accepting the Presidential Nomination at the Democratic National Convention in New York Online by Gerhard Peters and John T. Woolley, The American Presidency Project https://www.presidency.ucsb.edu/node/220260
I wrote my master’s thesis partially on the implementation of the Affordable Care Act and am a bit obsessed with Medicaid and welfare history. I have a ton of reading recommendations if you are interested - just let me know!
Not an affiliate link. I just wanted to make it super easy for you pick up an awesome book.