Robert M. Ball - Interview #3
This is another session in the Bob Ball oral history interview. This interview is taking place on April 3, 2001 in Mr. Ball's home in Alexandria. Again, Larry DeWitt is the interviewer.
Interviewer: Bob I want to go back and pick up a couple of things
that happened at the end of the 1950s, but before I do that, I noticed
that today is the 39th Anniversary of your
confirmation by the Senate to be Commissioner of Social Security.
Ball: Today? (Laughs)
Interviewer: It happened on April 3, 1962. So, I want to ask you a question about that and then go back if I can and change the subject again. But, since it's your anniversary date, I'm always curious as to how that sort of thing happens. What were the circumstances where you were offered the job of Commissioner? Were you lobbying to get the job? Did it come out of the blue?
Ball: Well, one thing I can say, I did not lobby for it. As a matter of fact, I don't think I ever went out to get any job in my whole career, which seems like a strange thing to say, but jobs just came along. During all the early part of my career--I started at grade three--I moved to the next grade before the automatic time would have brought me a pay increase. I remember that. I deliberately left the field to go to Central Office, but I didn't have a specific job in mind. But, no, I didn't lobby for the Commissioner's job. But it was, I think, more or less taken for granted that I would be the next Commissioner after Bill Mitchell.
We may have been into this before, but Altmeyer--and therefore Wilbur Cohen, who followed Altmeyer's ideas--had a strong feeling that throughout Social Security, all the way up to and including the Commissioner's job, jobs should be treated as career spots and that it was very important to stress continuity when the political parties changed. Of course they never had changed for 20 years when the program first started. But it wasn't a surprise to me that to the extent Wilbur had influence--and his influence was great in the Social Security area when Kennedy came in--that he would stress continuing a career person in the job of Commissioner. We knew that Bill Mitchell didn't really want to stay very long. I don't know how explicit we were, as I look back on it, but it was a reasonable expectation on my part to follow Bill. And Wilbur would be the one that would have the most influence in seeing I got the job. Technically, it was a Presidential appointment. And, of course it had to have the concurrence of the Secretary of the Department. But it was really Wilbur who would have been the influential person. And, actually, it was Wilbur who swore me in.
Now, another factor, to some extent, would be that John Macy headed the whole personnel operation at the top level. I had worked with Macy a lot when he was Chairman of the Civil Service Commission. He was Deputy Commissioner of Civil Service before that, and he was Vice President of the University that he and I both went to in the 30s. So I knew him, even as an undergraduate.
Ball: Macy came to my swearing-in, as a representative of President Kennedy. But it was really Wilbur who would have pushed my appointment. He would not have had any trouble anywhere with my nomination. I can't think of any place he would have had any trouble getting agreement on me. The hearing before the Senate Finance Committee was perfunctory, and the vote on the Senate floor was perfunctory. There were no serious questions were raised. I don't think I've ever looked at the transcript of the actual hearing, but it must have just been a few minutes. Sort of like, has anybody got anything to say? (Laughs) And then it was done. Have you looked at the transcript?
Interviewer: No, I haven't. That's an interesting thought, I would like to do that.
Ball: I mean, I would just be curious . . .
Interviewer: Do you recall who the Chair would have been of the Committee? This would have been the Senate Finance Committee?
Ball: Yes, Senate Finance.
Interviewer: Was this Russell Long? Or . . .
Ball: No, no, it wouldn't have been Russell Long. Might have been the older Harry Byrd. But there's no sense speculating about it, because it's a matter of record.
Interviewer: You mentioned your swearing-in. Sometimes there is sort of a technical swearing- in and then a ceremonial swearing-in. Did you do that or did you just have one swearing-in? Because I notice your swearing in took place on April 17th, which would have been two weeks after your confirmation vote.
Ball: I don't know what the explanation of that lag is.
Interviewer: Where did Wilbur swear you in? Was it at SSA?
Ball: That was a little ceremony at the Commissioner's Office in Washington. Bill Mitchell, the outgoing Commissioner, was there. Our wives were there. I'm sure I have a picture of that little celebration. Because I remember that Bill Mitchell looks so happy that he was leaving, he was just full of laughter. (Laughs) Bill was quite a nervous person and he really worried about a lot of things. Every time he would pick up a newspaper, he would be afraid that it would be something he had to deal with. So he wanted to stay to establish the point of continuity of leadership in spite of elections. But he didn't want to stay very long. I had every impression, he was glad to leave. There were a lot of other officials from the Department, that's what it was mostly, except, as I said, John Macy was there.
Interviewer: OK, who actually offered you the job? Who called you and said, "Are you interested?"
Ball: I think Wilbur.
Ball: I think it probably all came through Wilbur.
Interviewer: OK. At any point in that process did you have any conversation with President Kennedy about that?
Ball: No, no. I had conversations with him later about a lot of things, but not about taking the job. I think they just left it up to Wilbur.
Interviewer: Wilbur was, at that time, an Assistant Secretary, wasn't he? I don't think he was . the Under Secretary yet.
Ball: I don't know, that's easy to check.
Interviewer: I'll have to check.
Ball: That didn't make that much difference, as an interesting point. As Assistant Secretary for Legislation, Wilbur was the most influential person in the Department, as long as Ribicoff was there. The actual Under Secretary, under Ribicoff, was Ivan Nestigen, a former Mayor of Madison, Wisconsin. But that didn't matter to Ribicoff. He worked with Wilbur, and a close personal assistant, who was a young fellow from Laconia, New Hampshire, whose name for the moment I have forgotten, but whose father had established a significant law firm, a Democratic law firm, in Laconia--which had a Democratic Mayor in spite of the fact that New Hampshire, as a whole, was very Republican in those days. Those two people, with Ribicoff, ran the Department. Ribicoff, himself, didn't pay a great deal of attention because he had only been in that job, as Secretary, a short time when he realized that Cabinet Secretaries in American Government do not have very much power. They are at the beck and call of not just the President, but of the President's staff. The Office of Management & Budget (OMB), and the immediate White House staff, are more powerful than they are. He had been Governor of Connecticut, where you go ahead and do things, as a Chief Executive. He found very fast that he wasn't the Chief Executive of anything. (Laughs) And that to move on anything significant, you had to clear it. Well, that made him start running for the Senate almost as soon as he became Secretary. So he spent a lot of time on Connecticut politics. And Wilbur and this young man really ran the Department, and had the relationships with the White House, and so on. Now, you won't find that in any history books, but that's the way it really worked.
Interviewer: Right, that's what's important.
Ball: It's not unusual for Cabinet Secretaries to become rather quickly disillusioned, particularly if they were former Governors. Watch Tommy Thompson in HHS, and see how he feels after a year. (Laughs)
Interviewer: I want us to go on from this point and begin the subject of your tenure as Commissioner. But I just want to make sure that we covered a couple of things that, for some reason, I was thinking about this morning. One was the Curtis Subcommittee, and the other one was the Burr Harrison Subcommittee. It was interesting to me that when the Curtis Subcommittee was formed, one of the first things they did is they dragooned poor Arthur Altmeyer from Wisconsin and forced him to come back at the point of a subpoena to testify reluctantly before the Committee.
Ball: Was it actually a subpoena?
Interviewer: Yes, they actually issued him a subpoena. I saw it in his papers at Wisconsin the last time I was there. I was just wondering whether SSA had much involvement with the Curtis hearings, and whether the Bureau had any involvement, whether you had any involvement.
Ball: After Altmeyer testified, I testified for three days. I was the central witness for them. The main hearing was me. It was quite interesting that Altmeyer had finally just got fed up, he patiently responded to their questioning for quite a long while. They would keep asking him to read this or that into the record. And, he finally said, "Read it yourself!" (Laughs)
They were not very good at their job actually. The Council to the Subcommittee was a man named Bob Winn, and he had as an Assistant, Karl Schlotterbeck, who was the staff person for the Chamber of Commerce Social Security Committee.
Curtis had a real goal in mind. He had a proposal for a substitute Social Security plan. He favored flat benefits to everybody, paid, not out of a wage tax, but out of raising money some other way-exactly how, I've now forgotten. But it was similar to the Chamber of Commerce proposal, which was a blanketing-in proposal with the wage-related system on top--a double decker. Except that very few people were actually eligible on the second deck at the time they proposed it. The Chamber proposed that flat benefits be paid out of the contributions that workers had built up, and they ran smack into a strong resistance from labor on that theory. If they had been willing to use general revenue, they might have had a chance to pass it. But, of course, they weren't. They wanted to build a barrier against liberalization of the program. That was the Chamber's goal. Curtis' position was even more radical. He just did away with the program and substituted a flat benefit program, like a low-paying Townsend-type plan.
Now, in order to advance his own plan, Curtis' strategy was to show that the system as it had operated up until then was unfair, to the point of being ridiculous. His emphasis was upon a series of questioning that went to things like how if you had five quarters of coverage you wouldn't be eligible but if you had six quarters you would be. And how much you paid in taxes for the five quarters as compared with what you might have paid-in for the six quarters. There was a series of technical questions like this designed to make the program look silly in order to say, "Well, the only fair thing to do is pay everybody the same. That these distinctions are being made, doesn't make any sense." Well, as a matter of fact, the initial years of a contributory Social Security system do have a lot of fine-line distinctions that are very hard to defend in terms of who paid how much and things of that kind.
So, it wasn't really hard to show these borderlines and difficulties, but they lost the attention of the press completely after the first day or two. The first day, when I was testifying, they focused on paying people abroad. The fact that the American Social Security system actually paid benefits to people in foreign countries, which they attacked, was a front-page story. They really had the attention of the press on that. It was made to look like a give-away to foreign countries. But after that, it was so boring--the series of detailed questions about eligibility requirements and benefit computations and so on--that the press completely lost interest.
The questioning was carried on not by Curtis and the other Congressional members--, except very occasionally they would say something--mostly it was Winn and Schlotterbeck. They weren't so much trying to catch me, as to get stuff in the record to show what I said. They were trying to show the ridiculousness of the early days of the contributory system. So sometimes they would actually give me the questions ahead of time, so that I knew what to be prepared for. The General Council's office and our staff developed very good answers. I'm sure those hearings would be fun to read again. I don't think I have a set of them, but they may be in those bound legislative histories that the National Academy has my set of.
But it was very wearing for three days, answering all day long for three days, and I got very tired of it. But it didn't really go anywhere. We just usually said, "Yes," to their questions (Laughs) and gave them the technical details, and there was no real fuss anywhere.
Of the Democrats on the Subcommittee, the main defender of the system was John Dingle's father, John Dingle the present Congressman from Michigan. His father was a member of that Subcommittee, and he would intervene to be helpful now and then, when he could. I've forgotten the other Democratic members, but I believe that Jere Cooper, or Wilbur Mills, were on that Subcommittee. But, that's something to check-I think it was Mills.
I think we may have mentioned it earlier, but very early in the Republican Administration, at the same time that they had gotten control of the House for the first time in a long while, Mrs. Hobby established a group of advisors that came to be known as the Hobby Lobby. And Curtis used to come to those meetings, as well as running these hearings.
Interviewer: Oh, I didn't know that.
Ball: Then Folsom started to come as Under Secretary of the Treasury-and he was very favorable toward the program. So we had laid out in these meetings of the Secretary's advisory group a lot of what was going on in relation to Curtis' plan, the Chamber of Commerce plan, and Folsom's defense of the present system, and I was the staff director of that Hobby Lobby group. So those were interesting times.
Interviewer: I'm sure that Altmeyer perceived himself and Curtis to be in a kind of political tug- of- war. They were trying to get Altmeyer to say things about the program that would undermine it. And he was trying just as hard to avoid doing that. I think he clearly saw the Curtis hearings as a politically-driven agenda, which is why he declined to appear and they had to subpoena him to get him to testify. Which is a funny idea. I don't know if it's unprecedented. I mean, they subpoena folks for investigative hearings, but not to come and give your opinion. (Laughs)
Ball: Information. . .
Interviewer: Yes, for information. It was such a strange idea. But, anyway . . .
Ball: And they kept giving him documents that he had signed, and asked him to read them into the record. That's what burned him up after a while.
Interviewer: Yes, I can imagine. What I want to know is whether you, in your role in the Bureau, saw the Curtis hearings in the same way? Were you trying to resist the political pull that Curtis was trying to exert? Or did you approach this in a very neutral, matter-of-fact way?
Ball: Let me say how it really worked.
There's no question that we all perceived Curtis as making a major attack on the program and wanting to wreck it. His whole purpose was to get rid of the program and substitute his own system. So he was an enemy of the program and we were the defenders of the program. The strategy, or tactics I guess, was, however, to not escalate the hearing, but to be very matter-of-fact in response, to keep it at a technical level, and to bore everybody to death. We never got excited about anything. Just tell them, you know, yes $6.07 here is the minimum you could get, and 14 over there for that, and yes, that's right Congressman, and so on. So it's kept very matter-of-fact, but we realized of course what he was up to. He later became a Senator, and was on the Senate Finance Committee, and continued to be very critical of the program. But he never again was in a position to do anything like those hearings.
Interviewer: You mentioned Marion Folsom from Treasury being a defender of the program. This was around the same time as the Hobby Lobby. I guess my question is, how did the Eisenhower Administration react to Curtis? Did they support him? Were they indifferent to him? Did they oppose him? You were in the context of a new Administration here, and it was unclear in those early days exactly how the Administration viewed the program.
Ball: That's right. They didn't know themselves how they viewed it yet, when Curtis started. Not in so many words, but the general message I got from Mrs. Hobby was, "Yes, go up and testify and do your best and we'll make up our minds later." (Laughs) I had gotten fairly close to her fairly quickly simply because Altmeyer had sent me over to help her staff this group of advisors. I knew some of those people from before, Sonny Marshall of General Electric, Reinhard Hohaus of Metropolitan. Hohaus became the Chair of this little Hobby Lobby group.
I asked Mrs. Hobby to come over to Baltimore, as people generally were impressed in those days with the operation in Baltimore--being able to look up your Social Security number and find your record for you in, I don't know, 20 seconds or something. So we had gotten along together increasingly well over time. When Curtis started it was fairly early, and Mrs. Hobby had never given any indication of whether she would support me for a job and let me stay there or get rid of me the next day. She just was non-committal. But, in effect she said, "Go up and do the best you can." (Laughs) They didn't have any particular position yet.
Folsom, on the other hand, had a long background in support of Social Security. He was involved in the original Advisory Council to the Committee on Economic Security, before there was any program. Then he was a member of the very important 1937-1938 Council, and again a member of the very important 1947-1948 Council. I knew him well because of the Councils. He was very helpful within the Administration. He was a really strong supporter. But even the business people and the conservatives that Mrs. Hobby consulted with took the view, ultimately--which was the insurance company view--that Social Security was a good idea. The program was a good idea, just be sure you don't let the benefits get very high, but cover everybody under it. So they backed this report on extension of coverage. Well, you can't back extending coverage to a program you don't approve of. So, indirectly, they came, not quickly, but within a few months, to be supporters of the program. And Mrs. Hobby went with me to go see the Senate Finance Committee Chairman, Millikin, to urge him to cover farmers and farm workers. So, they got behind it, but it took a while.
Ball: And, I don't know whether you ever found that speech I gave at West Point to a Regional Conference or not.
Interviewer: No, I haven't.
Ball: That was early in the new Republican Administration. I wanted to encourage the field staff with the idea that the whole program was not going to disappear. But she wouldn't give me a message for them. I had to do it on my own.
Interviewer: All right. Let's talk then just for a little bit if we can about the Harrison Subcommittee, which is a few years later after disability has been enacted. Basically they end up reviewing the disability program. I think they started out as critics of the disability program and they were going to really rake us over the coals--especially over our administration of the disability program. But by the end of that process they had pulled their horns in a little bit.
Ball: Oh, yes, they completely turned around, I'd say.
The disability program was very controversial. It took several attempts to get it passed. It had been advocated as early as the 1947- 1948 Advisory Council. And, you know the steps, with a temporary freeze in 1952, and the permanent freeze in 1954 and finally 1956 before cash benefits actually were passed.
Their was strong opposition from the AMA, and the insurance companies. Business, as a whole, supported the insurance companies. And it was almost all around the issue of the great administrative difficulty of making disability determinations. The thought on the part of the conservatives was that a government agency would not be able to resist the political attractiveness of just paying benefits. That there wouldn't be the backbone to say "no."
Partly as a rule of general philosophy, but also as a strategy, my view had always been that we should do the best we possibly could administratively to follow what we took to be the views of the leading members of the two committees of Congress that were involved in the legislation--the Ways and Means Committee and the Senate Finance Committee. It was clear to me that they had passed a conservative program and wanted it administered conservatively. So, that's what we did. We made careful and strong determinations, disallowing a lot of claims. Well, it didn't take very long before the Congressmen reacted against what we were doing and they started saying, in effect, "Gosh, we didn't mean for you to not pay these people. Our constituents need these benefits. What the hell are you doing?" (Laughs) And that's what caused them to set up the Harrison Subcommittee--the fact that we were so conservative in awarding benefits. So that's the way they started, to look at what we were doing in the determination of disability.
They spent a lot of time, and they were very conscientious. They spent a lot of time in Baltimore, they did a lot of looking at the way determinations were actually made, and the collection of evidence, and so on. At that time I was just beginning a period in which I made lots of chart presentations, as a way of testifying and making a case for things. I made a full-scale chart presentation to the Harrison Subcommittee on the process, and the numbers, and the appeals, and how many we reversed on Reconsideration, and how many on appeal. It's all in the hearing there, and I think it was quite interesting.
The net result, by the time Harrison Subcommittee got through, was that they said, in effect, "Yes, Social Security is doing exactly what we told them to do, but we told them the wrong thing." So they recommended a series of liberalizations to be put into the law. Dropping age 50--you had to be 50 or older to receive disability benefits-and a lot of other things, they recommended be liberalized. So, the net result of the Harrison Subcommittee-and Burr Harrison was a very conservative Congressman--was substantial liberalizations in the disability program.
Interviewer: Did SSA favor those liberalizations?
Ball: Oh, yes.
Interviewer: Did we steer the Committee to these answers?
Ball: No, "steer" is too strong. We very much favored them, this is what we wanted. But we didn't lobby them for it. They emerged out of a very careful investigation. They wanted our help as to how to make it better because they said, in effect, "We passed something that isn't good enough. What do we do to fix it up?" And so we worked with them on a series of recommendations to make it better.
Interviewer: One minor little recommendation that did come out of the Harrison Subcommittee, that I think SSA was opposed to, was the idea of publishing the Listings of Impairments. Prior to that time, these were "administrative-confidential" documents. The Committee required us to publish them and make them available . . .
Ball: I had forgotten that actually came out of the Harrison Subcommittee, but it may well have.
But, yes, there was a running disagreement with the legal profession, which most Congressmen belong to, over the rights of claimants to know everything there is to know. Our view was that if you told people exactly what the adjudication rules were that you had to meet to get disability benefits, people would shape their evidence to meet the rules. That you wouldn't get an objective determination. We found that position untenable over a period of time, to have rules kept secret from people. We finally came to the conclusion, forced to or not--I don't remember how much forcing there was, versus a realization that you couldn't stand behind that position.
But it does make it more difficult to run a program like that and prevent . . . well, it's not fraud, but it is shaping of evidence toward a variety of screening rules. It's a huge program. Social Security's disability program is, undoubtedly, the biggest in the world. There are millions of applications to deal with. The only practical way to handle the determinations was on the basis of a set of criteria to rule a lot of claims immediately in, and a lot of claims that were obvious noes, to deny them. Then other rules that got more sophisticated on the group of claims in-between. Well, this is a nationwide program, with thousands of people making these determinations all over the country, and you have to tell them pretty specifically-- if you are going to get uniformity, which is the only fair--you have to tell them pretty specifically what the rules are for their determination. And if you tell them and the lawyers for the claimants at the same time, you've handicapped your determination process.
That's what the argument was all about, and it's certainly true that we started with the notion that to do a good job, we needed to know some things about how we were handling screening rules for claims that we didn't let the claimants in on. It is better for administration, probably, but it is not good legal procedure. So we changed.
Interviewer: I haven't looked at this in a long time, so I don't remember any of the other liberalizations that came out of the Harrison Subcommittee. Are there any others that occur to you off-hand?
Ball: I haven't looked at it for a long time either, but there were a series of them.
Let me tell you this: the climate of adjudication is determined, not only by the specifics in the law, but by what Committee reports say the Congress intended. The Committee reports, particularly in the Ways and Means Committee, go into considerable detail as to what the Committee means by putting in a given provision--. on Social Security, in every aspect of it. They tell you how they want you to interpret it. Now, even that's not nearly enough. You have to then go to regulations and then the Claims Manual instructions, which are all further detailed. But the Committee reports themselves really tell you whether the Committee now wants this with some emphasis in the direction of "let's pay some claims" or whether the direction is, "Gosh, don't pay them if you can help it." I'm obviously making this too black and white. But Committee reports tell an Administrator what the intention is behind a lot of the actual legal words. The Committee reports don't legally control, they're supposed to write it in the law if they want it to control. But they tell you what the guys who wrote the law had in mind when they wrote it. If you want to carry out the law according to what the legislators really wanted, you look at the Committee reports for interpretation and climate. And the Harrison changes clearly went in the direction of a more liberal administration. Where the first time around, if you read the reports, they would all be full of fear that we would go too far in paying claims. So, it was not just the details in the law itself, but the climate that changed.
Ball: We still did a much tougher job, a much more objective job than private insurance ever did in disability. That's not just because we're better and smarter in the government. It was partly that disability insurance does not stand by itself in private insurance. It's sold as part of a package of benefits. The employer, who is going to be the one who buys your product from this insurance company rather than that one, frequently wants to use the disability program as a way of getting some marginal workers off his payroll. He's disappointed if he isn't allowed to put on the disability rolls somebody who is borderline, in terms of whether he could perform some job. He wants to get rid of them by putting them on disability. And that's true of disability in the federal service, too. It's used frequently by administrators to--in a more humane way than firing--to get people who have long service, who have done well for an organization, moved out earlier than the normal retirement age would move them out.
Well, Social Security in running a disability program is not selling anything to anybody. It doesn't have to worry about that specific thing. So, it was possible for us to make decisions that could be more objective in the sense of meeting the criteria, regardless of what the employer wants or thinks, or so on. So, the record of Social Security disability administration is quite strict, compared with the record of private insurance--which is the exact opposite of what people had expected.
Interviewer: Yes, all right.
I'm thinking now that we might shift our subject and start talking about health insurance, because the story of health insurance actually begins around this time in the late 1950s when some proposals start floating around. So let's turn to that.
Already by the late 1950s, we're beginning to see serious conversations about some kind of health insurance program, as an adjunct to Social Security or as a stand-alone system How early did SSA get involved in that? How early did the Bureau get involved in that? How early were you involved in those kinds of issues?
Ball: Well, you have to go back earlier than that. The Committee on Economic Security in 1934 in the end did not recommend health insurance. That was an obviously logical part of their job, to look at the question of health insurance. My understanding--and I have no personal knowledge because I wasn't around--but my understanding is that Roosevelt was afraid to take on the health insurance issue along with all the other issues in the cash social insurance program, because of the tremendous opposition of the physicians. He was afraid he'd lose the whole thing. So, in effect, the Committee on Economic Security never put him on the spot of recommending to him something that he didn't want to have. So, it was not in the original proposals.
Roosevelt himself never specifically endorsed any plan of national health insurance. Although he did generalize in ways that would have included national health insurance, like the Four Freedoms, which you would think would require government to act with a health insurance system. But these are broad and quite vague. He also claimed credit for the phrase, "insurance from the cradle to the grave," which would involve the major risk of health. But he never specifically had any bill that he supported in health insurance. Harry Truman was the first President to do that.
But all the time during the Roosevelt New Deal era, the Social Security Board felt completely free to advocate national health insurance. Roosevelt didn't disapprove of it, he just didn't put his own reputation on the line to get it. But the Board was very active in promoting it. I. S. Falk, whose was head of research for the Social Security Board, was in that job primarily because he was an expert in health insurance. And the Board had conferences and other ways of promoting health insurance that drew a lot of Congressional opposition, and opposition from the AMA of course, and it was a very controversial thing that the Board pushed. But the first time the Board was successful in getting Presidential backing for national health insurance was from Truman. When Truman was elected in his own right--you remember, he was just barely elected, and nobody had expected him to get re-elected except Truman himself-and Truman had very little influence with the Congress, but he was for it. But that didn't get you very far.
The only people who were really scared by Truman's backing of national health insurance was the AMA. They took it seriously. They put on a tremendous campaign to prevent something that was not going happen anyhow. We, within the Social Security Administration, started--almost as soon as Truman had made the recommendation--we started to back off of that in our own thinking and started saying, "Well, this isn't going to actually pass. What can we do that would have a chance? What kind of a first step within a national health insurance plan could we devise?" That's when the notion of health insurance for Social Security beneficiaries came up. We had, we thought, a built-in defined group of people who the public might see as uniquely needing government health insurance as against buying private insurance because they were already identified as old or widowed or orphans. So, we started to pursue that and that was quite early. That would have been still in the Truman Administration, toward the end of it. The Federal Security Administrator, who was anxious to be thought out for a Vice Presidential candidacy on the Democratic ticket the next time, took that on as his "attention getting" proposal.
Interviewer: Are you talking about Paul McNutt?
Ball: Not Paul McNutt. Oscar Ewing. Both Paul McNutt and Oscar Ewing were in this position, but at different times. It was Ewing who took on what later became called Medicare.
Ball: And Altmeyer was involved with him around this issue. The Bureau of Old Age and Survivor's Insurance, as distinct from the Commissioner's office itself, started to get involved in this issue too. The Commissioner's Office, and Research in the Commissioner's office with Falk, had been doing stuff on health insurance for a long time. But the Bureau of Old Age and Survivor's Insurance started to get involved when it became a question of a limited program of insurance for Social Security beneficiaries. In other words, Old Age and Survivor's Insurance beneficiaries. At one time I actually located a very early memorandum, I forget who even signed it now, but out of the Bureau, recommending this kind of a program. I was involved in that. But the Bureau didn't particularly take stands like that as a Bureau, but some of us who were working in the Bureau, as individuals, would also be involved in things like this.
Now that never got anywhere until the 1950s really. Then it gets picked up by Labor as the practical first step. It is, in some ways, a very peculiar thing that a country would undertake to cover first in a health insurance plan the most difficult group, that would be the most expensive, and for whom, in a very practical sense, you get the least for your money because they are not going to live very long, relatively. The place to put a limited amount of money in health insurance, from a rational standpoint, would be kids. So the selection of the elderly Social Security beneficiaries was purely a political idea. Because we thought that it could easily be made clear that private insurance couldn't cover the elderly because they had low incomes and yet they used--I forget now whether it was two-and-half or three times as much hospitalization--as the average among younger people. The way private insurance finances a program, is on a yearly, pay-as-you-go basis. So that people who are at risk are charged premiums related to that risk as they go along. So that there would be very high premiums for the elderly because they use so much hospitalization, and yet they had incomes about half of what other people had. So, as the group, you could make a very good case that they would not be taken care of by private insurance.
Interviewer: And, in fact, they weren't being taken care of.
Ball: Right, right.
Interviewer: They would have unmet social needs.
Ball: Right. And the plans that they were under, to the extent that they were under anything, were very limited--like ten days in the hospital, or something like that. Also, the elderly could be a good strong voting block and personally be in favor of it. So it was pushed pretty much on those grounds. And it went on for a long time. It was, I'd say, roughly ten years from the time we got serious about a Medicare program until it actually passed in 1965. And it had different degrees of intensity from time to time.
By the early '60s, it was a major push by the Democrats and by Labor. And the main obstacles were Wilbur Mills in the House, and Kerr in the Senate. It wasn't really a Democratic position. It was a liberal Democratic position. Mills was very concerned about what this might open up, and so was Kerr. That's the origin of the Kerr-Mills Bill, which was a precursor of Medicaid, and which was really designed to head-off a universal Medicare-type plan and substitute just a means-tested basic program.
Interviewer: You knew Mills very well, and had a lot of dealings with him over the years. Why was it that he resisted health insurance? Was it what you just said, that he was concerned about the financial cost? Or were there more dimensions to it than that?
Ball: Well, I presume it had more dimensions. Mills was a conservative, not just in social policy, but he was a cautious man. He did not want to be the sponsor of anything that would not pass the Congress. He would not have been in favor of a Medicare program until he thought it was feasible to get the Congress to vote for it. I think it was both conviction, that it was a risky thing to start down that road from a financial standpoint, and a feeling that he couldn't get the votes for it in those early days anyhow. But later on, he just became a plan barrier to it, even though with his support I think it could have gotten passed three or four years before it did.
In the Senate, it was equally touch and go. Kerr was the most influential person on the Senate Finance Committee, even when he wasn't the Chairman. Byrd was the Chairman. Old Senator Byrd was very much against the program, and Kerr was against the program. Kerr worked very closely with the doctors in Oklahoma, who were against it. Wilbur Cohen helped them set up the Kerr-Mills Bill, which was designed to prevent Medicare. Wilbur, of course, was really for Medicare. That got Wilbur into a lot of fuss with his usual allies in labor and liberal groups. They thought he was betraying the Medicare program. But I agreed with Wilbur. What history shows us, if you have a category of programs on a means-tested basis, it really helps you get social insurance later on, rather than be a final solution that people point to and say, "Well, you don't need social insurance because we already have a means tested program." It doesn't work that way. People are not satisfied with a means-tested program and they will want to reduce the assistance cost by social insurance.
Interviewer: All right. Let me just go back and pick up a couple of milestones from earlier developments, and tell me if you had any involvement in them. I'm just looking at my chronology here. So, I have this little chronology here with some dates. I see that in September 1959 the Secretary of HEW issued a report to the Committee on Ways and Means entitled Hospitalization Insurance for OASDI Beneficiaries. So, as you said, we were working on it, on this idea, already in the 1950s. Do you recall that report?
Ball: I'm not sure. I'm not sure if this is the right report or not, but let me tell you about a report.
Ball: On the Ways and Means Committee--which had jurisdiction of course over both Medicaid and Medicare, as well as the cash benefit programs--a Republican Congressman from Missouri named Tom Curtis-not Carl Curtis--was a major opponent of health insurance in general, and specifically, of Medicare. In the hearings before the Committee, his main tactic was to ask reams of questions and require a great deal of research and hard work to get him answers. No matter what you did, his conclusion at the end was, "Well, we obviously can't act on this now because we don't know enough." As a result of this kind of continuing thing, Ida Merriam was asked--by then she was the Chief of Research in the Social Security Administration itself, not the Bureau--was asked to do a report on the whole question of health insurance for Social Security beneficiaries. I think it was a great job. She really pulled together masses of material that responded to all the legitimate questions that had been raised. That was presented to the Committee. It didn't stop Curtis, but it was a big step forward. It was a very good job, scholarly and diplomatic and well done and well said. I think that's probably the report you refer to. I remember Curtis coming to hearings with books piled high on the table in front of him and indicating things that needed to be looked into. (Laughs) Before you could possibly consider such a hare-brain scheme, you have to know all this stuff. (Laughs) So, I think that's the story. So that's a report worth looking at.
Interviewer: OK, I'll do that.
Ball: If it's some other report, let me know. But, I suspect that's it.
One broad background point, that it is worth readers having in mind, is that the Ways and Means Committee, all through the time I had anything to do with legislation from the standpoint of being a government witness, was extremely thorough and conscientious. The Ways and Means Committee really did look very, very carefully into whatever they passed. I'm only familiar with the Social Security welfare/health insurance areas, rather than taxes. But, I'm sure they were thorough on taxes too. They used to spend months on important bills, going over things in great detail.
We were always represented in the executive sessions. I personally was in almost every executive session. I think I probably could say, every executive session on these subjects. Wilbur Cohen was in most of them too. And they went at it, and Mills let everybody on the Committee participate. The Legislative Council's Office, which is the arm of the Congress' staff which writes bills for Congressmen, were always there. They were a great help to Mills, always. The Committee actually did the bills themselves in the end. What started an important bill going was that kind of month-long, two-months long, maybe longer, consideration--sometimes carrying over two Congressional sessions.
Then it goes to the Senate Finance Committee, which did not, in those days anyway, undertake anything like the detailed work done in Ways and Means. They would rather take the House bill and say, "Change it here. Change it there." And then send it back for a Conference Committee between the two houses-typically, not working more than a couple of weeks on the bill. But, there were exceptions. The Senate spent a long, long time on a bill that was H.R.1, that involved a lot of different things. And, they developed their own version at great length. I was in on all those Executive Sessions. I would sit right at the same table with the Senators, sitting, usually, next to the lowest-ranking Senator around the table. Vice President Gore's father was a member of that Committee, and Abraham Ribicoff was a member of that Committee, and Russell Long, of course, and Clifford Hansen, a very conservative guy, who I sat next to a lot. He leaned over to me one day and said, "Do you know what the definition of a conservationist is?" And, I said, "No." And he says, "Somebody who built his mountain cabin last year." (Laughs)
Interviewer: (Laughs) That's good, that's good.
The Eisenhower Administration was initially opposed to health insurance. As late as 1960 we have Arthur Flemming issuing a statement saying the Administration . . . well, here's his quote, "I want to make it clear that as an Administration, we will oppose any program of compulsory health insurance." That was March 1960. And I know it got caught up in the 1960 election campaign with Kennedy advocating health insurance. What about that period before Kennedy came in?
Ball: Well, all the time that Flemming was Secretary, he tried everything he could to get some kind of a program agreed to by the Administration and submit it to the Congress that would, at least partly, fulfill the purposes of helping Social Security beneficiaries with their health costs. Some of them were State-based, some of them were income-tested--he tried everything. The guy who was really the honcho of all of Flemming's approaches was Alan Pond, an Assistant Surgeon General at that time. I was involved quite a bit. I was at most of the sessions where he testified at Ways and Means because Medicare was always in the background. Flemming himself would have been glad to have Medicare. But he couldn't get the Administration to support it. The Administration was much more conservative on the whole than Flemming was. Flemming was a Republican by accident in many ways. He and Elliot Richardson both had views very similar to, not just Democrats, but liberal Democrats, on most things.
I must have told you the story about the couple of days when, through Bob Burroughs, it looked as if the Eisenhower Administration might actually support a Medicare plan. Robert Burroughs ran a pension consulting business out of Manchester, New Hampshire and was the Republican National Committeeman from New Hampshire. He was one of the first people to get Eisenhower to declare that he would run for President and seek the Republican nomination. He went to Europe to consult with him when Eisenhower was still the General in charge of European forces. So Eisenhower always had a fond memory of Bob Burroughs, who was so important in getting him to be President, through backing him in New Hampshire, which was a key State then as always.
Burroughs had been a member of one of the Advisory Councils that I was very much involved in. I wasn't actually a member, but I sat with all those Advisory Councils as Bureau Director, Deputy Director, or what not. I always spent a lot of time with them, so I knew Burroughs well. Burroughs not has a business in Manchester, New Hampshire, but he has a summer place in Canterbury, New Hampshire--a big old colonial farm, with a big pond or lake on it. Eve Burns, who was a Social Security expert on many Advisory Councils, also has a place in New Hampshire. Both of them are dead now, but they had places in New Hampshire, nearby. And, of course, I had a place in New Hampshire, on Bear Island. Well, the three of us, having known each other on Advisory Councils, used to get together in New Hampshire every once in a while during the summer, recreationally.
Burroughs was in favor of a Medicare program. Burns was too and, of course, I was. So, the three of us worked up a memo to the President. I wrote most of it. It was for Burroughs to take to Eisenhower, giving in a couple of pages, the best arguments that we could boil down to a case for the Administration supporting it. Burroughs went to see Eisenhower. Eisenhower in effect said, "That sounds pretty good. Go over and talk to Flemming about it." So Burroughs goes, with the direction of the President, to Flemming, who has been struggling to find some conceivable way to do something, and in comes Burroughs with a full-blown Medicare plan, apparently with considerable backing from the President. He is just overjoyed to have this. Nobody knows about my involvement; it is Burroughs to the President. I don't know whether Flemming ever did know about my involvement, which was stretching my role as a civil servant a little, but I did it on my own time during my summer vacation. Anyway, my being openly involved would not have helped anything. So, for a couple of days, it looked like maybe the Administration would come up with something along this line.
Interviewer: What year was this that we're talking? Do you recall what year it would be?
Ball: I could find it. But, it's when Flemming is Secretary and Eisenhower's still in office.
What happens though is that Flemming starts to deal with it. And that means involving OMB, and so on. As soon as Maurice Stans, who was head of OMB, hears about it he goes to the President and in effect says, "You can't do that. During the campaign, you pledged to the doctors that you would not support anything like this. You just can't do it. I mean, it would be terrible." So Eisenhower backs right off and that's the end of that incident. Stans could out-trump Flemming on policy almost always in that Administration.
Interviewer: I also wanted to ask you Aime Forand. Did you have any involvement with Congressman Forand and his various bills that he was developing during this period.
Ball: Yes. The Labor Movement and some senior citizen groups--not AARP, but some senior citizen groups-- started to back Medicare. They got Aime Forand from Rhode Island, who was on the Ways and Means Committee, to support them. Going down the rank, he was the first Democrat on Ways and Means willing to be a supporter of the bill. So that's how it is that the Forand bill is talked about all the time.
It begins to be a national Democratic party position, even though the heavyweights in the Congress are not necessarily for it. But it starts to be something in the Democratic National Committee. And the Democratic National Committee and the Labor Movement between them produced a new organization, the National Council of Senior Citizens. The core membership of which was the retiree groups of the unions. It was really created to push Medicare, that was it's role. They became very active in demonstrations, and mass meetings, and letter writing campaigns, and meetings on the Hill, and they put out a very effective pamphlet--something like "Three Generations for Medicare." That's not the exact title, but the idea that they were pushing was that in paying for the bills of the grandparents, you relieve the parents from having to pay the very big medical expenses of their parents. And that leaves more room for the parents to take care of their children. So it helps all three generations. That was the idea.
It was always touch and go. That Medicare program really was on the verge of passing many times, but it never quite had enough support to pass. It really took Lyndon Johnson's election in his own right, in what counts as a landslide in American Presidential politics. Johnson's victory was so overwhelming that what Wilbur Mills did, as a good politician, was to see that Medicare was going to pass. So where he had been resistant before, he ran right in front of the parade and led it. And the first bill that passed is called the Mills Bill.
Interviewer: Did the Bureau help Congressman Forand, with the background material, information, research?
Ball: I suspect it was not as much directly to Forand as to his allies, like Nelson Cruikshank and the Labor Movement. Nelson Cruikshank was on many Advisory Councils, and was a close friend of mine, and he was very active in the health insurance argument. So it was probably more that way. Alvin David would have known him well. And Irv Wolkstein, who was a planner in the health insurance area, was probably involved.
Interviewer: What about you? What was your activities? What were your activities in the health insurance area during this period before Kennedy came in--at the end of the Eisenhower Administration?
Ball: I never had any formal roles. I was a civil servant, but we always took the view--at least Altmeyer, Cohen and I took the view--that we would provide information and assistance to anybody with a legitimate claim on the resources of the federal government. That we would try to make the best possible legislation, whether we agreed with it or not. And on that broad principle, we helped develop bills for Republicans in Democratic Administrations and for Democrats in Republican Administrations, and for outside groups like Labor, as part of our job. We didn't think that the political party in power in the Executive Branch owned the resources of the federal government. We thought the resources of the federal government were available for help whether or not we or the Administration agreed with the position of the group.
Interviewer: Something that you said just made me think of a slightly different topic for a second. During this period Wilbur is back in academe, and Altmeyer is retired, and you're still in the government. But you did have an association with those folks and with some other folks, who were kind of an informal circle of people who were connected. In fact, Berkowitz calls it "the apparatus" in his biography of Wilbur. He talks about the "Social Security apparatus," which was this informal association of people who had an interest in this.
Ball: I find that greatly exaggerated.
Interviewer: OK. Tell me how that worked.
Ball: I don't think I ever tried to change Ed Berkowitz' mind, but . . .
Interviewer: Well, here's your chance. (Laughs)
Ball: It didn't really operate like that. If there is a fault in Ed's book on Wilbur it is that his sources are almost completely Wilbur's own papers. He does not really go out of his way to find out what other players at the time are doing and thinking, and so on. It's a book that is almost entirely drawn from Wilbur's own sources. And you would get the impression, if you looked just at Wilbur's papers (Laughs), that he was involved in everything, and had everybody kind of working for him everywhere. But that wasn't really what was happening.
I didn't see much or hear much from Wilbur when he was not in the government. I was off on my own, working with people on my own. It wasn't as if there was some master minding or partnership involved. It just wasn't like that. I can hardly think of occasions or subjects where there was any significant exchange, except we might be at the same conference in Michigan, which used to hold conferences for Social Security.
And Altmeyer had just about practically dropped out of Social Security policy work. I tried to get Altmeyer to serve on an Advisory Council, and he refused to do it. He said in effect that he was too devoted to the way the program had developed so far to be much use on a Council that would be involved in trying to change it. The implication was he would find it too upsetting. So he did not want to be part of that.
I worked very closely with Wilbur whenever he was in the government. But the idea that there was something going on when he wasn't in government is exaggerated. It has truth in it to the extent that Wilbur kept working with the Congress on his own. But the idea that somehow he was very much connected with me, is just wrong. We just didn't do that, anymore than we had much to do with each other during the 1947 -1948 Advisory Council, as I already discussed.
I would have to see more specifics in Ed's book to see what it is that I disagree with specifically. But I know I got that same impression from Ed's book as you did. And I'm sure that's the impression you get if what you were looking at would be Wilbur's papers.
If you get to something specific, like the disability insurance program, and there are a lot of people who claim significant roles in the development of that--I'm sure completely honestly. I think Elizabeth Wickenden thought that she made the big difference by her connection with Lyndon Johnson--which was close. She was . . .
Interviewer: Her husband worked for L.B.J.
Ball: And L.B.J. was the National Youth Administrator in Texas when Wicky was in the central office. She knew him very well. I imagine she knew him better than any but the closest ten people in the world to him. And she thinks that she was able to persuade him, as Majority Leader, to go along with it. Wilbur thought that he made the difference. And I'm inclined to think that I did. (Laughs)
The key thing that I did was with Senator Kerr, who was the dominant factor in the Senate Finance Committee. I was sitting listening to him one day in the Committee hearings, I guess it was an executive session, in which he was saying that the major reason he was against disability was that it would be a hard program to control, and it might undermine the financing of the Old Age and Survivor's Insurance part of Social Security because it was the same source of financing. So it dawned on me right away that the thing to do was set up a separate Trust Fund and have disability entirely separately financed. And that seemed to make a big difference to Kerr.
Interviewer: You made that suggestion to him?
Ball: I made that suggestion.
So you see, there are lots of parents of successful programs.
But I don't remember Wilbur and me collaborating on anything significant. I think he and Wicky did, I think they talked a lot. They were very old friends from 1933 and 1934. They had--you can't call them offices, they worked on opposite sides of the the same row of file cabinets in a temporary building in Washington when the New Deal just barely got going. She was working on the immediate problems of welfare for farm migratory workers, and the National Youth Administration, all that sort of thing. And Wilbur, she thought, was doing pie-in-the-sky stuff on the Committee on Economic Security. But, they got to be close, and they always were close after that.
Wilbur was a good influence, but it was not with me. It was direct with Congressmen and Senators. It was not as if we collaborated somehow. I don't know if that's a terribly significant point, it's just "the apparatus," if there was one, didn't include me. (Laughs)
Interviewer: Bob, let's talk for a little bit about the things that happened in the 1960 election cycle related to health insurance. Let me just read you a couple of milestones here from my chronology, and then have you comment on whichever of these you have something you want to talk about. I see that in January 1960, Senator Kennedy introduced his version of the Forand Bill in the Senate. .
Ball: This is after the election?
Interviewer: No, this is before. This is January 1960. The election year, but the election hasn't taken place yet.
Ball: Right, there was a Special Session. They called a Special Session, didn't they?
Interviewer: I don't know.
Ball: Yes, I think so. There was a Special Session to deal with Medicare, but it didn't get anywhere. But, they had it.
Interviewer: Then later in March there is the quote from Flemming that I read you earlier where he said the Administration was basically opposed to Medicare. Then they tried to come up with various kinds of proposals. Then in April there was this interesting little thing where Senator Javitz and the Senate Republicans introduced their proposal, which was some kind of federal matching grants to the States to help pay the cost of health insurance, as a Republican alternative. Do you recall that?
Ball: Well, they were doing things like that every once in a while. That was a little early, but later, for two or three years, we were dealing with a group of Republicans in the Senate that varied in size up to as many as six or seven, but frequently only three or four. Javitz was the person who held it together, but it had Margaret Chase Smith, Senator Cooper, Javitz always, and a couple other liberal Republicans. We needed those votes to pass what was essentially a bill backed by the Democrats. We needed them to get enough to get through the Senate. That's when I had that disagreement with Wilbur.
Javitz felt that he needed something in the bill that he could point to as a Republican type provision in order for him to get this little group to support it. Wilbur thought that anything that had a voluntary aspect to it could be used as something to appeal to the Republicans. So what he did with Javitz and the group, was to set up alternative benefit packages, so that old people could chose this benefit package versus that benefit package when they signed up for Medicare. I thought that would be extraordinarily difficult to administer, along with everything else that was going to be difficult to administer in Medicare. I couldn't conceive, first of all, of making older people understand what they were choosing when they were comparing 45 days of hospital coverage in one plan versus 60 days of another type of coverage in another plan, each with a different level of deductibles. The administrators would have to deal with hundreds of thousands of complaints, because people would have made the wrong choice about half the time. They would have chosen a plan . . .
Interviewer: That didn't work out for their personal circumstances?
Ball: Yes, absolutely. I mean, there was no way to foretell what their future health circumstances might be, and so half of them would be disappointed with their choice.
But I couldn't make any headway with Wilbur. I felt strongly enough about it that I went to see President Kennedy about it.
I should have known better because when I walked into the Oval Office to talk with the President, Wilbur and Ted Sorenson were already there-- they had been meeting with him before I got there. The President was just going to give me a chance to say something, but they had already decided what to do. So I told them I thought that it would be chaotic-that it would just be chaos--to try to administer a program like that with voluntary choices of that size, that kind. The President listened for a while, and finally he leaned over and he patted me on the knee and said, "Well Bob," he said, "Let's have a little chaos." (Laughs)
Interviewer: (Laughs) Great story!
Ball: Wilbur said, "Well, we'll get this provision out before the bill finally passes. We'll get Mills to take it out." But, I was nervous because . . .
Interviewer: It's risky?
Ball: Yes, it's risky. Many things that you think you can get out, you don't. Then all of a sudden there you are trying to administer it. Wilbur didn't have to worry about administering it. He only had to worry about getting it passed.
Ball: Back to Javitz-we were talking about Javitz.
So that went on for two or three years when we were trying to get the support of the Republican group. They actually set up a study group. I've forgotten the details of that, but there was a study group set up that Javitz was very much involved in with outside experts, and one thing and another, to come up with a plan. They came up with a plan, which we did not adopt, but it was a rival plan along our lines.
Interviewer: The next thing I wanted to ask you about is that after Kennedy was elected, but before he took office, he appointed Wilbur to be the Chairman of a task force on something he called "Health and Social Security for the American People." To plan, I guess, their health program.
Ball: Yes, that's a fairly common thing for Presidents-elect to do between the time they're elected and they come into office. They get some experts on their side around to give them advice, and create the actual details of a plan. Wilbur headed this task force, and I helped him, and some other people at Social Security helped him, develop a set of Social Security proposals. The Medicare proposal was set. I mean, he knew he was going to be for that. He campaigned on it.
Ribicoff campaigned hard on Medicare too, but he had the wrong specification. (Laughs) Ribicoff was amazed when he actually got into the Administration and he found that the official proposal had a different age then he had been going all around the country urging. I forget what he had done, but the actual age that was in the President's proposal was 65. I don't know whether Ribicoff had been saying 60 or 67, or whatever, but it was something different than the actual age in the Administration's plan.
Actually, the proposals that Wilbur's task force put together--the cash benefit proposals--were quite conservative. They involved relatively small changes, because the emphasis was to be on getting Medicare passed.
Interviewer: OK. Then in the 1961 Amendments there were a set of modest changes, I guess we would call them. Such things as letting men take retirement at age 62, and liberalizing some of the benefit provisions for aged widows, the retirement test liberalization, things like that. Sort of a miscellaneous collection of relatively small issues.
Ball: Yes, that's correct.
Interviewer: Did some of that come out of the task force recommendation?
We soon took the position after that, that we didn't want to accept any cash benefit amendments that had a cost attached to them, because it was the tactics of the people opposed to Medicare to try to run up the cost of the cash benefit program so that they could argue, "Well, we really can't afford to do both." They could pass the cash benefit changes, and then we would be left without adequate financing for Medicare. So for several years, there was no increase in Social Security benefits, even to keep up to date with the cost of living, because we were holding out for Medicare.
Interviewer: But ultimately, there was a separate Trust Fund for Medicare. Couldn't you argue that those were separate financing streams? If you make a COLA for cash benefits, how is that going to take money out of the Trust Fund for Medicare?
Ball: Hospital insurance was to be financed out of the same Social Security contribution rates, or payroll tax, as cash benefits. And there were limits on how much Congress would be willing to increase the payroll tax. Anyway, it was the tactic of the opposition to push it up on the cash benefits side so that they would have a better case against Medicare.
Interviewer: So during the Kennedy Administration it sounds to me like numerous attempts, from lots of quarters, were made to try and get some kind of medical care program, and they all failed during this period.
Ball: Yes, but I wouldn't say there was anything really tried by the Republicans. Javitz had this tiny group of Republicans. But there was solid opposition from most of the Republicans in both the House and the Senate. Flemming's attempts were in the Eisenhower Administration.
So it was really us trying to get something that we could get a majority of the Ways and Means Committee Democrats to support. We were short three or four votes. Wilbur Mills controlled the Committee completely. We would try everything. We must have had five or six different plans that we thought maybe had a chance. Toward the end of this period , Mills kind of played us along. He never said, "Stop trying." He acted like maybe there would be a chance, if we got it just right. He encouraged us to believe, at one point, that if it passed the Senate and came to him in Conference-- without a bill in the House, but with a bill passed in the Senate--maybe he could vote for some kind of a compromise to get it started. But we tried that and that didn't work. He fell back on the idea that, since the House didn't have any provision at all, there was nothing that he could possibly compromise on. So, everything we tried, failed.
Interviewer: But Mills was the key in many ways?
Ball: Absolutely the key, yes.
The only thing that passed Medicare finally was, first, after Kennedy was assassinated Johnson made a big pitch in favor of carrying out the martyred President's legislative proposals, as a tribute to him. But, that wasn't enough. What really did it was Johnson's election in his own right with a landslide victory against Goldwater. And then Mills changed and took the lead in favor of Medicare.
Interviewer: So, during that period when Kennedy was still there, who was the "we" that was pushing it? Was it Wilbur and you? Was it the President; was he actively pushing this?
Ball: Yes, the whole Administration was for it. Most of the time, it was in Wilbur's charge. Wilbur really deserves more credit than any other single individual for the legislative passage of Medicare.
Interviewer: Wow, OK.
Ball: I was very much involved in it, but clearly as his lieutenant, rather than independently. When it came to implementing the program, I was very much in charge of it. But in terms of getting it through Congress, he was very much in charge.
There were times when there was a real argument within the Administration over who should be in charge for the President. Two different types of tactics were at stake. Ivan Nestigen was the Under-Secretary at HEW. At one point the White House, more or less, designated him to handle getting Medicare through, though Wilbur never really bowed out of it. But they had a difference of opinion on how to do this. Nestigen was for producing as much outside political pressure as you could, through demonstrations, and letter writing, and picketing, and one thing and another. Wilbur thought that the way to deal with Mills was quietly behind the scenes. They fought a pretty bitter fight with each other as to who was in charge and which was the right tactic.
I was sort of caught in the middle for a time there, helping them both, actually. But, in the end, Wilbur prevailed. And I think he was right, although there was something of each in the approach. There was nothing wrong in having the National Council of Senior Citizens lead boycotts against the Reader's Digest, or picket this and that, and hold demonstrations at the same time we were trying to quietly get Mills to change his mind. But Wilbur were always afraid of antagonizing Mills, so that he couldn't work with him. And some of the tactics discussed could have had that effect. On the other hand, the right kind of mass tactics didn't necessarily offend Mills.
Interviewer: And, of course, on the other side of it, during this time the AMA was mounting a huge campaign in opposition. I mean, even Ronald Reagan got his political start making pitches for the AMA and their campaign against Medicare.
Ball: Yes, there was a recording Reagan made--you should have a copy of it in the SSA Archives. There was an auxiliary organization to the AMA. The wives of physicians ran a program through this auxiliary organization, and Ronald Reagan did the record for them. They way it worked was that a physician's wife would ask her neighbors in and they would play the Ronald Reagan record were he encouraged them to fight Medicare.
Interviewer: It was a coffee, these were coffees?
Ball: Yes, and they would write letters to their Congressman about it. I got hold of that record in the campaign between Carter and Reagan to show how, in his own words, Reagan had fought Medicare. I played that record on the Presidential plane for the newspaper people. But, I got the record too late. Carter was already defeated.
Interviewer: I don't think you could have saved Carter.
Ball: Up until the last two or three weeks, at least we thought there was a chance. I went with Carter on Air Force One on a tour of Florida, probably the last week in the campaign. He was beginning to see by then that he was going to lose. But he hadn't thought that was necessarily the case two or three weeks earlier.
So Mills was the key guy in Congress, and Wilbur Cohen was the key Administration figure for getting Medicare passed.
Interviewer: All right, so after Johnson gets elected in 1964, things finally start to move.
Ball: It was really the overwhelming vote for Johnson when he ran in his own right.
Interviewer: And, this was clearly one of his priorities, something that he was running on.
Ball: Oh, yes.
Interviewer: I know Wilbur played some role in crafting the eventual form of bill. Some compromises were crafted that got Mills' support. How did that play out? Were you involved in that as well?
Ball: Oh, yes. I was involved in everything. Wilbur and I were together on everything. I was just making the point, though, that there wasn't any question in the legislative process that he was in charge and I was his helper.
Interviewer: OK, I understand.
Ball: Now, are you talking about Part B, how that came in?
Interviewer: Yes, talk about that.
Ball: The hospital insurance program, which is all the administration had been for--and only for elderly people, that's all they'd been for in recent years. It started with all Social Security beneficiaries, but it got down to just the elderly, and we dropped the little bit of coverage of doctor bills that there had been at one time. We were going to cover services doctors performed in a hospital, basically operations and stuff. But we dropped that on the theory that the AMA would have less standing in the argument, politically, if they weren't at all directly involved and the reimbursement only involved the hospitals. And we avoided certain complications by having only the elderly covered.
Well, this has been worked on and worked on for years, this bill. And unlike the American Medical Association, the American Hospital Association--although they formally opposed Medicare--was willing to work with us in trying to make the bill something they would like best, in case it passed. There were many hospital administrators who were in favor of Medicare (even though the AHA as a whole was not) because they were all having a big problem about having to take care of older people who didn't have the money to pay their bills. So to have the government have an insurance program that would pay the hospital, seemed to a lot of the administrators like a really pretty good idea. (Laughs) They were just dragged by the physicians into a coalition of all medical groups opposing Medicare, except for the nurses. The American Nurses Association was a strong backer of Medicare. And, of course, there were a few individual physicians, like Dr. Spock, who were in favor of it. Phil Lee of the Palo Alto Clinic--who later became Assistant Secretary of HEW--was for it. But it was just a handful of physicians because the AMA declared it, in effect, unethical for a doctor to support this government program.
So we had a bill on hospital insurance that was really well worked out and which had been polished with the hospital industry itself-- with Blue Cross/Blue Shield. So it was basically quite acceptable as a technical bill by the time that Mills decided to support it. Not a lot of work had to be done there, or in the Senate. The big thing was the overnight addition of Part B, a voluntary plan for physicians, which was thrown together in a great hurry.
Interviewer: Well, why don't you tell that story? How did Part B get thrown in?
Ball: Well, I really believe that it was a proposal that Mills pretty much put together quickly and tried out on us one afternoon, in an executive session of the Ways and Means Committee. His reasoning was that he thought he could put something together that everybody would have to be for. He was only defeated once on the House floor in all the time he was Chairman of the Ways and Means Committee-- while I was in government. And he didn't like that. He always liked to win. So, he had decided that the hospital part was okay. But he had committed himself to doctors organizations in Arkansas, not to be for compulsory coverage of physicians' services.
One of the big political rivals to the administration's hospital insurance plan was a voluntary plan that was supported by the ranking Republican on the Ways and Means Committee, John Byrnes of Wisconsin. He never expected it to pass, Byrnes never expected it pass. It was built on a private insurance plan that Aetna was selling. It was voluntary, and it covered much more than the Administration's plan, which was only hospitalization. So this Byrnes plan was something that the Republicans could point to and say, "Well, our plan is much broader than yours. It covers physician's fees, whether in a hospital, or in the office, or wherever. And it's got all this good stuff in it that you don't have."
The AMA had been pushing a means-tested program, that was their key. They weren't against taking care of people who needed medical care if they were poor, and they were willing to go with that. So they were for enlargement of the so-called Kerr-Mills Bill, which was in the law. They were for liberalizing that.
So what Mills did that afternoon, he said, "Well, why don't we take the Administration's proposal for hospital insurance and then add to it Mr. Byrnes' proposal-the part of it that covers physicians, so we would have a voluntary plan for physicians." (This became Part B) "Then let's take the AMA proposal," (which became Medicaid) "and put the three together."
Wilbur Cohen and I looked at each other, rather astounded, and said, in effect, "Well, we will have to consult on this and get back to you." The big allies of the Administration in trying to get Medicare passed was the labor movement. So we consulted right away with the people from the labor movement, both the CIO and the AF of L. They were quite reluctant. There were no hand-holds for cost controls in this voluntary plan of private insurance. The Byrnes bill really didn't try to control cost significantly. The labor movement was correctly worried about how you could actually administer a plan like this through the government without better ways of controlling fees. About all it said was that the services had to be medically necessary. This was a pretty wide-open type plan, and nobody liked the voluntary aspects. But after a couple hour's discussion, we agreed that it was better then nothing-that the only possible chance we had to get into the field of actually covering doctors was what Mills was proposing. So we decided to go for it, and we cleared it with the White House. We came back and supported it. And they put the two together, and that's how Part B of Medicare came about.
Now, there are people who think that isn't the whole story, that there was behind-the- scenes discussions of this--that it wasn't sprung on us quite they way I've described it. But I don't believe that. I think it really was a try-out by Mills, and nobody could think of a good reason against it. (Laughs)
Interviewer: Now, were the other members of the Committee present when he put this on the table?
Interviewer: How did they react? Did Congressman Byrnes jump up and say, "Well, Wilbur, thank you." Or anything . . .
Ball: Oh, on the contrary. He didn't know what to think. I think he thought he'd been taken in.
Interviewer: Yes, well, maybe he had. (Laughs)
Ball: (Laughs) Mills and Byrnes worked very well together.
Interviewer: So was there a debate among the Committee members about it at the time? Or was it too novel an idea?
Ball: There was no debate. The meeting just sort of broke up and we went away to see if we could accept it. And when we came back we said we could.
Interviewer: OK. So, once the deal was done, so to speak, it went through after that without a lot of trouble, is that right?
Interviewer: Were you there on the Hill when it was being debated and voted on?
Ball: Yes. It was fairly customary when Mills brought a bill out on the floor to have us there. Remember, although I was always representing the Executive Branch, the Ways and Means Committee didn't have much in the way of specialized staff. So we really acted, for Mills, like his staff. So very often when he had a bill on the floor, when he was in charge up in front--the way that House of Representatives is set up, if you're up front in the speakers area looking back, in the balcony there's a big clock in the center-he used to position me up there right beside that clock.
Interviewer: Up in the Gallery?
Ball: Up in the Gallery, directly ahead so that he could look up and signal me to come down because he wanted to ask me something, or give him some kind of help on a point he was making, or in response to some question. So, I was almost always up there, positioned there, and to an extent, participating.
That was true to a considerable extent also in the Senate, where I would be almost always in the Gallery. They can bring people on the floor in the Senate, by getting unanimous consent. Bob Myers, three or four times I remember, was on the floor so he could sit right next to a Senator to answer technical questions.
In one of the big debates on Medicare, Clinton Anderson, the Senator on our side, was debating Kerr on the other side, and Anderson got permission for me to sit right next to him, to help him in the debate. I remember well because when I went onto the floor there was an empty chair right up near Anderson who, being the bill manager, was right in the center of the Senate, standing upright, you know. I sat next to him, and Hubert Humphrey was two seats over. After it had been going awhile, old Harry Byrd, who always wore a white linen suit in the summer, comes walking across the floor and sort of looks at me, and then goes on. Somebody had the wit to say to me, "You're sitting in Byrd's seat." (Laughs) So, I got up out of there pretty fast.
Interviewer: But he didn't say anything to you?
Ball: He was a very polite gentleman. I'm sure he was nonplused at my being in his seat. But he didn't make any show of it until I got out and then he came around and sat in it.
Byrd was always against Medicare. But I put a lot of effort into modifying the degree of his opposition. I knew I'd never get him to be for it. But I got him to stop making speeches as if it were a Communist plot, or something completely out of the question. I climbed Old Rag mountain with him twice--my main object being to be closely enough associated with him that he couldn't think something I was for was completely evil. And that worked. He had three "Byrd's Nests" built in the mountains around Old Rag, for which he had given the money to the Forest Service to build these lean-tos, which were called "Byrd's Nests." Doris and I were his guests at a dedication of one of those. And another time we climbed Old Rag together. I guess it was three times that I camped out with him, to have this degree of effect in modifying his views. He became very friendly. But he never would be for Medicare. But he stopped ranting and raving about it, even that was helpful. (Laughs)
Interviewer: How did the floor debates go in the House and the Senate? Was there anything eventful that you can think of that?
Ball: The floor debates were good debates in those days, like the Anderson vs. Kerr debate in the Senate. They were not perfunctory. They would really go at each other and raise sensible questions. Many people would attend. I've been there when there were a 100 Senators on the floor to vote for something important like that, and they all show up and listen to some of the debate ahead of time. That seldom happens anymore.
Interviewer: So after it passed did you have any kind of celebration? Any sort of victory party?
Ball: There were parties after the passage of some legislation. I remember Russell Long, on bills that he was managing, taking us all down to his office, the Majority Whip office, and bringing out drinks. I'm trying to think specifically about Medicare, and it isn't coming back. I would not be at all surprised if there was something like that. We wouldn't actually have a formal party anywhere. There were celebrations later. I remember one put on by the National Council of Senior Citizens. I spoke at a rally in Manhattan that they put on that was a celebration of the passage of Medicare. Then we, very soon, were in the business of publicizing the Medicare provisions to get older people to sign up for it. But they were part rallies, and part information-giving. We must have had 10,000 people in a meeting in Cobo Hall in Detroit, that I spoke at.
Interviewer: We need to talk a lot about the implementation because, as you said earlier, then it became your lead. There's a lot of story to be told there about the implementation. I want to spend a fair amount of time on that. But let me just go back to the Bill signing at the Truman Library in Independence, Missouri. Did you go to Independence for the bill signing?
Interviewer: Tell me about that if you would.
Ball: Well, it was very much like President Johnson to make a great deal out of events. He was very generous toward his predecessors and would wrap them into his celebrations. Truman, as I said earlier, was the first President to back a national health insurance plan. So Johnson looked to him as the originator of what became Medicare. And it was very much like him to take us all with him down to Independence to sign the bill in the presence of President Truman. I'm sure you have pictures around of us at that signing. The Congressmen and Senators who were most involved in the program went. Wilbur and Altmeyer and I went, Cruikshank and other labor people went, and the Press of course.
Interviewer: Did you travel with the President?
Ball: I was in the second plane, it was called Air Force Two I think. But there were two plane loads, and I was in the one that didn't have the President on board. I was sitting next to Andy Biemiller, who was in charge of the legislative activities of the AFL - CIO, who had been very influential in getting this done. That of course is just sheer celebration, a bill signing ceremony. (Laughs)
Ball: Something I was reading on your Web site got the story wrong. It has a series of pictures of me with Johnson, and I guess some Cabinet Secretary, and a member of the public. And it's captioned that this person is receiving the first Medicare card. That's incorrect. The first Medicare card went to Truman. I think probably the second and third cards went to King and Anderson. I've got a picture of them getting the card from me, hanging on the wall there. I not only had a card for Truman, when I went down to the signing ceremony, but I had the first pamphlets about Medicare distributed on the plane on the way down.
Ball: That's pressing the appropriation a little bit. (Laughs) We didn't have any money to administer Medicare yet. But I wasn't waiting to formally get an appropriation. As soon as it became clear we were going to have a program, we started work. So we actually had a major overall pamphlet about Medicare, millions of copies, available at the time of the signing ceremony.
Interviewer: Now let me just clear up this matter about this picture of this other Medicare card with this member of the public.
Ball: That photo is probably one of the series that we did in order to get press attention for Social Security. What we would do is select like the ten-millionth beneficiary, or the 15-millionth beneficiary, and make a little ceremony out of that--having that person meet the President. But their only claim to fame was being, theoretically, the 10- millionth beneficiary. So he was probably one of those, and there are pictures of others too.
Interviewer: OK, I'll check it out.
(Editor's Note: Upon further research, we determined that the photo was an event in which an application form for Part B was completed and submitted by the first member of the general public, Mr. Tony Palcaorolla of Baltimore, Maryland, as a result of the mass-mailing of Part B application forms Mr. Ball discusses below. Although Mr. Palcaorolla was the first symbolic applicant from the general public, President and Mrs. Truman filed their Part B applications during the July 1st signing ceremony in Independence.)
So Medicare is passed and you have to start planning for implementation. What did you do next? What happened?
Ball: Well we had plans well-developed for implementation well before the legislation was passed-with the tasks that needed to be accomplished before the effective date of July 1, 1966. Various parts of the Social Security Administration had assigned jobs to do all these things.
One of the key things that happened--and all of these things were done at the same time, you can't do 'em sequentially, there isn't that much time--one of the key jobs was to sign people up for the voluntary Part B. You had to get a signature from them agreeing to have, at that time, a three-dollar premium deducted from their Social Security benefits-if they were getting Social Security benefits, or set-up some other way for them to pay the three dollars if they weren't Social Security beneficiaries. Well, this was quite a big job and we started with a punch-card mailing to all those on the Social Security rolls who were over 65, or within three months of 65. The mailing was a punch-card application, together with a pamphlet of information about the program. We sent the same sort of thing to recipients of civil service retirement benefits, for whom we had an address; railroad retirement, for whom we could get an address; and from internal revenue records for people for whom they had an address and for whom there was a reason to think they might be in the older-age group. Everywhere we could, we got lists of names and addresses-- from welfare rolls, nursing homes, etc. From any place where we could handle sending out applications in a controlled way. That is, we could send it out and know who we sent it to so that you could follow up if you didn't get a reply.
We made at least three mailings. We got people who responded to the first, and that ended them. Then we would deal in a couple of months with a group who hadn't replied, and then follow-up with that. We had the responses returned to Baltimore, because we would have had a difficult time routing them back to the correct local offices. But we had an arrangement with the Post Office that if they had an envelope that just said "Social Security," they would send it directly to the District Office that was in that area. But we controlled them centrally to make sure everybody was being followed up on.
There were still some that weren't being reached in this controlled direct-mail way, with punch card applications, so we hired some of the senior citizen groups to help. The National Council of Senior Citizens--and AARP, I think, but at least the National Council of Senior Citizens--to go into areas where it was likely that these were older people who had not been reached, and go door to door.
We had cooperation from all sorts of areas. The Post Office had signs on the sides of all their trucks, "Age 65, sign up on Medicare by (such and such a date) . . . go to your nearest Social Security office," Stuff like that. We had the Forest Service looking for people camping out in the woods. We used every way of reaching people that we could think of. And we did end up with about 95 per cent of the estimated number of people over 65 in the population actually having signed up and saying, "Yes I want it for three bucks."
At the same time this was going on, we had to contact every hospital in the country and certify it as meeting the requirements of a hospital under the law. That meant either they had to be certified by the Joint Commission on Accreditation, which is a voluntary group made up of doctors, and hospitals, and nurses,--there were four parts of it. If they didn't meet the accreditation standard--and smaller hospitals often didn't-- then they had to meet a set of standards that we had devised. We made contracts with every State through the Governor to designate a state agency, usually the Public Health Service of the State, to survey the hospitals for us that hadn't met the accreditation standards, but might meet the standards that we had set up that would apply mostly to smaller hospitals.
In addition to the accreditation, there were two other requirements. One was that they had to have a Utilization Review Committee, which at that time was not part of the Joint Accreditation standards, but was required by the new law.
The other new requirement was a completely separate operation that the Public Health Service and SSA ran about compliance with Title VI of the Civil Rights Act. That's a real story in itself. By the time we reached the deadline, we had 1,000 federal employees out in the field visiting these hospitals, because we had decided that we were not going to take anybody's word for how they were going to desegregate. We were only going let them in the Medicare program and pay them if they had actually desegregated. If in fact we had inspected and seen it. That meant that in semi-private rooms in the South, for example, people of these two races who had been separate all their lives, were to be assigned beds as they came into the hospital. And if that meant a black and a white sharing a room, that was how it had to be. And all the other facilities in the hospital had to be desegregated as well. About 500 employees of Social Security district offices and 500 employees of the Public Health Service were out in the field doing these inspections, to get these hospitals certified before the deadline date. And it worked. We got most of them in.
Now there was resistance from, as I remember, the Southern Baptist hospitals, who did not sign up right away--everybody came in later, but not right away. And it was necessary to meet the problems that arose with some of the Southern Senators by our being somewhat relaxed about emergency services. We had a rule that said even if a hospital is not participating for any reason, including non-compliance with the Civil Rights provisions, we nevertheless would pay for emergency care in such a hospital if it was the nearest hospital to the patient. We weren't going to be responsible for deaths, say, from an automobile accident because we wouldn't pay the nearest hospital. So we started by being relatively lose about the definitions of an emergency at the time that the program went into effect, and then tightening it up gradually until we had full compliance, without the potential disaster that might have arise from a complete denial.
We got through that period really well. We had accomplished, really, the complete desegregation of hospitals in this country, almost overnight. In contrast to the field of education, where the government accepted plans to desegregate in the future, and then never did get it done.
At the same time that was going on, we had to be in touch with every doctor in the country to explain what his or her patients were entitled to. And get them to participate to the extent that they needed to participate. And, as I said, we had to have contracts with every Governor.
I gave a chart-talk at the White House, to the Cabinet, which listed all the tasks that we needed to perform and where we stood on them. This was about three or four months before the final implementation date. But, it's a chart that shows the number of pamphlets issued, the number of people signed up, the number of hospitals certified, and so on. That talk is now in a little publication recently put out by the National Academy of Social Insurance. That publication also includes a discussion with Art Hess and me about the implementation of Medicare, and other things about Medicare.