By the 1960s, the system of private health insurance in the United States was well established. In 1958, nearly 75 percent of Americans had some form of private health insurance coverage. By helping to implement a successful system of voluntary health insurance plans, the medical profession had staved off the government intervention and nationalized insurance that it had feared since the 1910s. In addition to ensuring that private citizens had access to voluntary coverage, the AMA also was a vocal opponent of any nationalized health insurance programs, suggesting that such proposals were socialistic and would interfere with physician income and the doctor-patient relationship. The AMA had played a significant role in defeating proposals for nationalized health insurance in 1935 (under the Social Security Act) and later in defeating the proposed Murray-Wagner-Dingell (MWD) bill in 1949. The MWD bill would have provided comprehensive nationalized health insurance to all Americans. To ensure the defeat of the proposal, the AMA charged every physician who was a member $25 for their lobbying efforts (Marmor 2000).
While serious proposals for government-sponsored health insurance were not put forth during the Eisenhower Administrations of 1952-1960, proponents of such legislation worked to ensure that their ideas would have a chance at passing in the future under more responsive administrations. They realized that the only way to enact government-sponsored health insurance would be to do so incrementally -- and they began by focusing on the elderly (Marmor 2000).
Offering insurance to aged persons age 65 and over provided a means to successfully counter several criticisms that opponents to government-sponsored health insurance had aimed at previous bills. Focusing on the elderly allowed proponents to counter charges that nationalized health insurance would provide health care to individuals who were generally able to pay for it themselves. It was difficult for opponents to argue that the elderly were not among the most medically needy in society, given their fixed incomes and the fact that they were generally in poorer health and in greater need of medical care. Supporters also tried to limit the opposition of the AMA by putting forth proposals that only covered hospital services, which also stemmed criticism that said nationalized health insurance would encourage extensive -- and unnecessary -- utilization of medical services.
Medicare Provisions
The political atmosphere become much more favorable towards nationalized health insurance proposals after John F. Kennedy was elected to office in 1960, and especially when the Democrats won a majority in Congress in 1964. Passed in 1965, Medicare was a federal program with uniform standards that consisted of two parts. Part A represented the compulsory hospital insurance program the aged were automatically enrolled in upon reaching age 65. Part B provided supplemental medical insurance, or subsidized insurance for physicians' services. Ironically, physicians stood to benefit tremendously from Medicare. Fearing that physicians would refuse to treat Medicare patients, legislators agreed to reimburse physicians according to their "usual, customary, and reasonable rate." In addition, doctors could bill patients directly, so that patients had to be reimbursed by Medicare. Thus, doctors were still permitted to price discriminate by charging patients more than what the program would pay, and forcing patients to pay the difference. Funding for Medicare comes from payroll taxes, income taxes, trust fund interest, and enrollee premiums for Part B. Medicare has grown from serving 19.1 million recipients in 1966 to 39.5 million in 1999 (Henderson 2002, p. 425).
Medicaid
In contrast to Medicare, Medicaid was enacted as a means-tested, federal-state program to provide medical resources for the indigent. The federal portion of a state's Medicaid payments is based on each state's per capita income relative to national per capita income. Unlike Medicare, which has uniform national benefits and eligibility standards, the federal government only specifies minimum standards for Medicaid; each of the states is responsible for determining eligibility and benefits within these broad guidelines. Thus, benefits and eligibility vary widely across states. While the original legislation provided coverage for recipients of public assistance, legislative changes have expanded the scope of benefits and beneficiaries (Gruber 2000). In 1966, Medicaid provided benefits for 10 million recipients. By 1999, 37.5 million people received care under Medicaid (Henderson 2002, p. 433).
Growth of Medicare and Medicaid Expenditures
Figure 3 shows how Medicare and Medicaid expenditures have grown as a percentage of total national health care expenditures since their inception in 1966. The figure points to some interesting trends. Expenditures in both programs rose dramatically in the late 1960s as the programs began to gear up. Then, Medicare expenditures in particular rose sharply during the 1970. This growth in Medicare expenditures resulted in a major change in Medicare reimbursement policies in 1983. Instead of reimbursing according to the "usual and customary" rates, the government enacted a prospective payment system where providers were reimbursed according to set fee schedules based on diagnosis. Medicaid expenditures were fairly constant over the 1970s and 1980s, and did not begin to rise until more generous eligibility requirements were implemented in the 1990s. By 2001, Medicare and Medicaid together accounted for 32 percent of all health care expenditures in the U.S.
Figure 3:
Medicare and Medicaid as a Share of National Health Expenditures, 1966-2001
Source: Calculations by author based on data from the Centers for Medicare and Medicaid Services (http://cms.gov).
Notes: Percentages are calculated from price-adjusted data for all consumer expenditures, 1996=100.
Endnotes
1 In Canada, fraternal societies were the primary source of sickness benefits and access to a physician in the event of illness. The role of fraternal lodges in insurance declined significantly after 1929. See Emery 1996 and Emery and Emery 1999.
2 These changes may also have increased physician quality, thus leading to an increase in demand for physicians' services that put additional pressure on prices.
3 Stock companies are companies that are owned by stockholders and who are entitled to the earnings of the company. Stock companies are required to hold reserves to guard against insolvency (see Faulkner 1960, pp. 406-29 for a detailed discussion on reserves). Mutual companies are cooperative organizations in which the control of the company and its ownership rest with the insureds. Mutual companies may be required to have reserves, or to engage in assessment liability (in which insureds must pay additional amounts if premiums fall short of claims). Both stock and mutual companies pay taxes.
4 However, the enabling legislation did not give the Blue Cross plans free rein. They required the plans to be non-profit, and to allow free choice of physician by subscribers, and some specified additional requirements. New York was the first state to enact such enabling legislation in 1934, and 32 states had adopted special enabling legislation for hospital service plans by 1943. Other states exempted Blue Cross plans by categorizing them strictly as nonprofit organizations (Eilers 1963, pp. 100-07).
5 Scofea, p. 6. See also Inland Steel Co. v. NLRB (170 F. 2d 247 (7th Cir. 1948) and Eilers, p. 19.
