George thanks for having me. Steve you have devoted a considerable amount of time studying medicare and medicaid. Legislation was signed into law in 1965 by lyndon johnson. Part of the Great Society program. Take us back to that time. And how this legislation was significant at the time and how it has evolved in the last 50 plus years. George thats a great question to start off with. Medicare and medicaid passed in july, 1965. Medicaid was really an afterthought in the legislative drafting process. The laws ratification shortly after the assassination of president john f. Kennedy meant that there was a greater focus on the medicare law and there were certain historical reasons for this. Medicare began and grew out in 1960 which also grew out of the medical aid for a program, which was a new deal era program that began in the 40s and 50s. For that reason, most policymakers and legislators were focused on delivering medical assistance public Insurance Options for the elderly who were at risk of bankruptcy and high costs from endoflife care. So when medicaid was appended to the law it was seen as a way to extend a Similar Program to those who were deemed medically indigent. At first, medical indigence was seen as a way to capture people that did not have incomes below the official poverty line. So, say, if a family of four in new york made 6,000, if they made 6,001 they would not have qualified for the prior systems. Medical aid assistance. What medicaid did was expand medical aid for those below the poverty line. Steve lifestyle was different in the 1950s and 1960s. If you were in the category that didnt have insurance, what did the elderly do . What were their options . George this is the age of charity care. So hospitals werent necessarily seen as the sites for hightech care. At the turn of the 20th century, if you were welltodo or had sufficient income, bedside manner was still the predominant mode of delivering care. It was after the technological advances of the early 20th century, the introduction of antibiotics and innovations from surgery that made hospitals much more attractive. From the getgo, hospitals were built around charity care. Elderly folks who could not afford that care often times relied on religious organizations. Its why we still have an Extensive Network of catholic, jewish and other religious care. Often that care would be on a charity basis. A lot of elderly people would rely on mutual aid organizations. Oftentimes organized around ethnic affiliation, whether polish or italian and these organizations would be able to gather funds to pay for the medical care of the elderly. If you didnt have access to a charity Care Hospital or mutual aid association, or if there wasnt some kind of statebased program, the elderly basically went without it. So, this was a particular pressing problem that president johnson saw in his time as a representative in texas. He saw elderly folks going into poverty, going into debt or withholding or forgoing medical care and he really saw that population as a centerpiece for health care reform. Public Health Insurance reform. Steve you mentioned this a moment ago. The state of Public Hospitals especially in large cities like washington, new york, philadelphia, boston, miami. George Public Hospitals were part of this transformation. If the Hospital System did not have hightechnology or efficacious medical care, it became more so by the mid20th century, and this attracted municipalities to take on much more of a social welfare function in providing that care. In the case of new york city, there was a department of hospitals that preceded what is todays health and Hospitals Corporation and that department of hospitals organized a variety of Charity Hospitals that were loosely affiliated and did not have centralized control. What new york city did with the founding of the corporation in 1969 was consolidate the budgetary process for these hospitals and bring them under one aegis. New york is quite unique in that regard. At the time of hhcs founding in 1969, new york controlled over 50 of the nations Public Hospitals. When i cite that statistic a lot , of people look askance and say that sounds a little too high for one place. But, mind you, because public it is hospitals, municipal hospitals were not the norm. Again, catholic or charity Care Hospitals were. When new york consolidated the and sowhen new york consolidated the system, it brought to the , fore a municipal Hospital System that outmatched many other cities in terms of size and scope. Steve does not explain why new york had probably half of the Public Hospitals if not more in the country when you compare to other largeat to cities like chicago or los angeles . George exactly. Before the health and Hospitals Corporation, the department of hospitals created a coordinating body for Charity Hospitals. But after the founding of hhc in 1969, the whole system became fully municipal. Another important change was taking the budgetary appropriations process out of the city council and placing it into a quasipublic notforprofit organization. The thought process being that getting the budgetary process out of the parochial squabbling of City Council Persons would improve the efficiency of the organization. History shows that wasnt quite as successful as it was intended. Steve if you could, explain the debate in this country and on capitol hill. As you will know 10 years after , president obama signed the Affordable Care act, we are still debating obamacare. So what was happening in the early and mid1960s. Has significant was the assassination of john kennedy in pushing this legislation by president johnson and what was it like on capitol hill . George that is a great question. I see the present political circumstances as almost a return or patterning of history. Because when you look at the passage of medicaid and the resistance of Southern States to expand medicaid under the category of medical indigence you see a lot of rationales or concerns that you hear from Southern States who are conservative governments in the south today. At the time, people were really concerned about costsharing and the debate between liberals and conservatives also became a debate within liberalism itself. A debate between incremental or gradual reform or a push toward universal health care. Sort of debate within liberalism itself was , constrained by a Wider National political economy. For example, i look at in my research a series of rich transcripts from the medicaid hearings in 1968. In the new york city hearings, there is a really interesting debate between republican governor Nelson Rockefeller and jacob javits. Democratic actually the democratic senator jacob , javits. Its actually the republican who advocated for a more expensive radical change to the Health Care System toward universal health care. Understanding the senate and the National Political economy and the constraints therein advocated a more incremental approach. At his right flank was russell b. Long, the senator from louisiana, who proposed cutting the category to become more like the official poverty line and making it more like a welfare medicine program. In my research i look at the 1965, 1967 year. 1967 was when an amendment was passed to make medicare more firmly a welfare medicine program. Seymour the real expansion and requirement in more liberal states like new york, minnesota, california, massachusetts running up against more conservative states like louisiana, alabama and other states in the south who wanted to keep a very constrained category for Medicaid Eligibility and didnt want to necessarily be funding more expansive programs. Steve staying with that timeline, you had a number of conservative president s. Richard nixon, gerald ford, jimmy carter. You had high inflation and high unemployment rate. If this was rolling out across the country, what was happening politically in the country . This was the 1970s. George its very important that you mention rising inflation because this was a signal moment that i see as hobbling the more expansive aims. Again, going back to 1965, that law, because it was an afterthought, senators and legislators didnt think medicaid would surpass medicare. It quickly becomes a popular program, at least in the states that wanted to fund it. Because of its costsharing structure versus medicare which was really federally based. In new yorks case, when the 1965, they used medical indigence standard which was more liberal to expand access to 1. 5 million new yorkers. When dixiecrats in Southern States pushed back against that law and expansion the result of restricting medical indigence meant that one million new yorkers were taken off the rolls. So the wider political context of that was the johnson era and the Great Society was seen as an era of excessive liberalism even though it wasnt necessarily purely focused on expanding equity and so with richard nixon, he begins to pull back a number of demonstration projects, namely like Health Clinics and the Regional Medical program. And he begins to deemphasize the focus on inpatient care in favor of out patient care. And so as inflation intensifies in the 1970s, 1973 being the Opec Oil Crisis and the nixon shock where the direct convertibility of the dollar to gold is canceled, a freefloating Exchange Rate for currencies, a number of macroeconomic shocks push the wider political and National Context away from medicaid. And this culminates in the administration of a democratic president jimmy carter, who had to grapple with a second wave of hyperinflation in 1977 and 1979. And this led carter to push for hospital Cost Containment legislation that the chamber of commerce and a group called Washington Business Group for health pushed back against. They called for voluntary, rather than mandatory inflation targets. Nonetheless, both pieces of carter legislation failed. But it showed how the end of the 1970s, this focus on cost versus equity became a bipartisan consensus. Steve looking at the overall budget, medicare, medicaid, social security, those are the big drivers of the federal budget. What was it back in the 1960s and do you see this trajectory continuing into the future . George even before the 1960s, a number of Health Service administration scholars and policy experts began to see a slight uptick in medical inflation but it was not as egregious as the 1970s. This early awareness through the 1960s was part of the impetus of trying to rationalize medical care. Nonetheless, by the 1970s it becomes very clear that medicare and medicaid had some role in increasing Health Care Costs by bringing more people into the system. Especially people who previously did not have care. We know, especially with the experience in obamacare there is , a slight uptick in costs when you bring people who are sick or and didnt have prior exposure to the medical care system into the system. But the program did successively expand and has continued to expand through the years. Even as nixon, for example, looked for cutbacks and tried to two, the hill burton and Hospital Construction act in 19 66, you see him expand medicaid. It becomes expansion under categorical means. So, nixon oversees an expansion of the law to include funding for people suffering from kidney and renal disease so theres a kidney dialysis category added in 1972. The history of medicaid in the 1980s becomes a progressive addition of other protected groups. Instead of having a wide category of medical indigence he under income it becomes about , status. So pregnant women are added in , the 1980s. The s chip program is added in the 1990s to address childrens medical care. So you see a slow progressive , expansion under the larger categories. Why i say this is patterning history, is with obama or the Affordable Care act you see a return to the medical indigence moniker. But instead of medical indigence its framed as a sort of lower middleclass entitlement. The structure of the law is the same. Steve finally, why did you select this particular area as part of your research at princeton . George i was really, really curious. My Research Began by looking at the history of the hivaids epidemic. Thats a relatively recent history and it is still current problem. A lot of the scholarship focuses on the social history, activist history or the interpersonal bias between americans. I was kind of understanding that history but also a little unsatisfied as to how it explained the sort of structural resources at hand to handle the epidemic. I really wanted to reach back in time, in particular back to medicare and medicaid which was , just 15 years before the epidemic, to think about how this First National really truly nationwide Program Changed the Health Care Structure in ways that deemphasized patient care, inpatient care, Palliative Care and increased the burdens of health care on persons who received Outpatient Care and returned to their homes to recover. Or who relied on meager subsidies for pharmaceuticals. I found those answers in the 1960s period and i found the reason why the Health Care System was so inadequately built to meet the aids epidemic. Those transformations were taking place in the 1970s. It was really important for me to push back into time to give a prehistory of the aids epidemic but also of u. S. Health care in the latter 20th century. Coming out ofts the new deal and the Great Society. Steve george aumoithe, thank you for joining us. On American History tv. George thanks for having me. History tv,merican featuring events, interviews, archival film and visits to college classrooms, museums and historic places. Exploring our nations past, every weekend, on cspan3. Tonight, on lectures in history, we visit the James Madison University Classroom of professor Andrew Witmer to hear about how rural areas evolved after the civil war. Using his hometown in maine as a case study, he looks at Rural Industries and the rise of tourism aided by the expansion of the railroads. Heres a preview. Haines wrote, flower gardens are numerous. Ornamental grounds are often seen. And find cottage homes and villas, dust such as one would expect love and happiness to dwell in, are found upon every street. It sounds like a Thomas Kincaid painting, doesnt it . It sounds almost too good to be true. Depicted small town, as the opposite of the ills of the city. Outn, it is like stepping of modern life, with all of its problems. And being able to recharge your batteries for a week in the countryside. As the town created and marketed its tourist landscape, it joined the widespread metacessation of bread e whites of rural romance life. The qualities that lead young people to leave the cities, could be emphasized to draw that he people to the country. Even if for only one week. Joined the classroom at 8 00 p. M. Tonight to learn more at 80 eastern to learn more about how small towns changed after the civil war, here on American History tv. Next on history bookshelf, aboutd carwardine talks his book, lincoln sense of humor
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