The Evolution of Medicare


WHEN President Lyndon B. Johnson flew to Independence, Mo., on July 30,1965, to sign the Medicare bill, the occasion marked the official beginning of a major new social welfare program that was destined to involve many billions of dollars, have far-reaching effects on the patterns of medical care in this country and, in one way or another, touch the lives of most Americans. As one of the most important pieces of social legislation to be enacted since the passage of the Social Security Act in 1935, Medicare thus provides us with a significant opportunity to study the process by which social welfare policy is formulated in the United States.

If one were to ask how social welfare policy decisions are made in this country, the answer would be deceptively simple--through the mechanism of social legislation. But if we examine this mechanism more closely, we find an extraordinarily complex, many-faceted process which may bring into play a diversity of political forces and require decades to complete. Indeed, scores of books have dealt with the subject. But for those who desire a basic understanding of how social legislation is enacted--whether they be employees of the Social Security Administration or other Government agencies, social workers, administrators, teachers, students, or other citizens--it should be possible to describe some of the elements of the process and point out some of the factors that influence the outcome. Using Medicare as a case history, that is what will be attempted in this monograph.

In the course of our brief account of this long debate, we will define and discuss six elements of the legislative process : (1) The development of an idea, (2) the emergence of organized leadership, (3) the building of political support for the proposal, (4) bargaining or negotiations between key interests, (5) public debate and voter referenda on the issue, and (6) decision-making in the legislature.

This breakdown of the legislative process into six distinct elements, or stages, is of necessity somewhat arbitrary. They do not necessarily occur in the order presented above, nor are they unrelated to one another. Usually, in fact, they are thoroughly intermixed. For example, negotiation between major interest groups may bring about a political consensus for a proposal, thereby damping public debate and speeding action in the legislature. The relationship between these elements will be discussed in greater detail in the Introduction and the chapters that follow.