This piece was commissioned by guest editor Jon Ashworth.
After World War II, as the British Labour Party was creating the National Health Service, President Harry Truman saw the defeat of his proposal for universal health insurance for all Americans – a proposal that opponents had denounced as “socialized medicine”. It surely wasn’t that. What Truman had called for was a payroll tax to finance the cost of all medical and hospital services. He was careful to emphasise what he wasn’t for: “Socialized medicine means that all doctors work as employees of government. The American people want no such system.“
What they got instead was no NHS, no universal insurance, no new system at all. The state of your health continued to be perilously dependent on the amount of your wealth. This hit retirees especially hard; millions of them had little or no income other than the modest state pension they received from social security. They were more likely to fall ill and constantly lived under the shadow of threatened medical bankruptcy.
In his 1960 campaign, John F Kennedy called for Medicare, universal insurance for seniors, paid for by a trust fund again financed by a payroll tax. National coverage for everyone, something like the Truman plan, seemed impossible and was hardly talked about at all. Among political leaders, there was a pervasive awareness that during that earlier healthcare battle, the Truman administration had been pilloried as “followers of the Moscow party line”. But Medicare too encountered fierce opposition. An actor named Ronald Reagan produced a record assailing this more limited proposal for “imposing statism”.
The bill was defeated by four votes in the Senate in 1962 and conservatives blocked any vote in the House. After Kennedy‘s assassination and Lyndon Johnson’s landslide victory in 1964, the gridlock of falsehoods, fears and smears about socialism collapsed; Congress passed and Johnson signed not only Medicare, but Medicaid to provide coverage for the poorest Americans. He held the signing ceremony at the Truman Library in Independence, Missouri, in the presence of Truman himself, where he hailed his predecessor as “the real daddy of Medicare”.
Along with social security and the Peace Corps, Medicare soon became one of the most popular programs ever written into American law and life. But it’s important to understand what Medicare is not: it’s not an NHS for the elderly. There are deductibles and co-pays and participants need to buy supplemental insurance in the private market to be fully protected, since, for example, only 80% of doctors visits are covered. There are also premiums for hospital coverage of up to $422 a month. Costs borne by patients have escalated over the years.
Medicare’s provisions would seem bewilderingly complex to a British public accustomed to the NHS. The program certainly isn’t perfect; neither is Obamacare, which extended health insurance to millions of other non-elderly Americans. Both are complex because they had to be in order to pass in a political system wary of social democracy. Both face financial pressures, Medicare later, and Obamacare now as the Trump Republicans subvert it and premiums rise. Think of the latter as an American analogue to the austerity that has inflicted so much damage since 2010 on the NHS.
And not content with his party’s repeated attempts to obliterate Obamacare, the soon to retire Republican Speaker of the House, Paul Ryan, yearns as he has for years to end Medicare as we know it. He would replace guaranteed levels of coverage with vouchers; seniors would use them to buy health insurance in the private marketplace, with no assurance that the vouchers would actually enable them to secure the benefits they currently receive under Medicare. One of Ryan’s motivations is plainly ideological hostility to any kind of public social insurance. He claims that the change would save money – at whose expense? – and shore up the Medicare trust fund, which in fact could be made whole by a modest rise in payroll taxes. The other expedient reason for Ryan’s proposed cuts in the program is to offset some of the $1.9tn in new federal debt that will result from the Trump tax breaks for big corporations and the wealthy – tax breaks which themselves undermine the Medicare trust fund.
For now, though, there is very little chance that a Ryan-like assault on Medicare will see the light of legislative success. President Trump is not just indifferent, but apparently allergic to the idea – primarily, I think, because he views it as political poison with the older and rust belt voters who gave him a slim electoral college victory in 2016. The math is stark: change 40,000 votes out of millions cast in three states, and Donald Trump would be back eating his Big Macs in Trump Tower. But if he is re-elected, Medicare could soon be on the chopping block since his promises are not worth the air they are spoken on.
On the other side of our political divide, Medicare is increasingly becoming a template for Democrats who want not only to save Obamacare, but to move beyond it to “Medicare for All” or even some form of single payer.
The Medicare program passed in 1965 will echo through the 2020 election, when healthcare is bound to be a major and potentially even decisive issue. In that sense at least, Britain and America are not so different and the simple, fundamental principle at stake is the same one Labour vindicated in 1948 and is fighting for again – that healthcare is a right and not a privilege.
Robert Shrum was a longtime Democratic consultant and strategist in the US and other countries. He now holds the Carmen H. and Louis Warschaw Chair in Practical Politics and serves as director of the Institute of Politics at the Dornsife College of Letters, Arts and Sciences at the University of Southern California.