The Government Did Work, Once Upon a Time

Lest you be tempted to regard the troubles plaguing the new Medicare prescription drug benefit as normal "teething," Jon Cohn writing for The New Republic reminds us that the inauguration of Medicare itself was silky smooth:

What Bush could learn from LBJ on Medicare: "The administration's initial response will be familiar to anyone who recalls the early months of the Iraqi insurgency or the first few days after Hurricane Katrina. 'This is going very well,' a spokesman at the Center for Medicare and Medicaid Services (CMS) said on January 4, with apparent seriousness. When the difficulties became too widespread for even the Bush administration to ignore, officials fell back on another well-rehearsed excuse: Glitches were inevitable given the nature of the task. 'We know there are going to be bumps in the road,' another CMS spokesman said. 'It's a new program.'

Most people probably think this makes sense, since most people think that the government always bungles such massive undertakings anyway. But consider what happened when the Johnson administration rolled out Medicare for the first time in July 1966. Back then, the obstacles were even more daunting than they are today. Rather than simply adding a benefit for a relatively narrow class of services (prescription drugs), introducing Medicare meant establishing an entirely new insurance program in just eleven months. There were concerns about hospital capacity: What if seniors held off on medical treatment until the benefit kicked in and then flooded facilities? There were also racial complications: LBJ had insisted that Medicare refuse payments to hospitals that didn't abide by federal civil rights guidelines. Since many Southern hospitals remained segregated, senior citizens there might have had no place to go.

So what happened on the day that this complex program was implemented? Thousands of senior citizens simply went to the hospital and got the health care they needed. 'There were no crises that I remember,' says Yale University political scientist Theodore Marmor, who worked in the office overseeing Medicare implementation and went on to write The Politics of Medicare, the program's definitive history. Newspaper accounts from the '60s back him up. Under the headline 'medicare takes over easily,' a Post writer described the program's first day as 'a smooth transition, undramatic as a bed change.' Three weeks later, the Times affirmed that 'medicare's start has been smooth.'"

Why was it so smooth? No secret ingredients - just administrative simplicity, single-mindedness of purpose, and competent management. The Medicare drug benefit debacle fails on all these counts: the program is maddeningly complex for pharmacists, insurers and especially for seniors; the program is maddeningly complex because it is intended not so much to relieve drug expenses as it is to benefit drug companies and somehow prove the advantages of private markets and choice in healthcare; and the program is run by people with no experience in social insurance programs, supervised by people with an ironclad reputation for holding absolutely no one accountable for even the biggest mistakes (exception that proves the rule: Brownie).

For the last few years I've thought that more government involvement in health care might cause longer waiting lines and some restriction in patient options, but supported it nonetheless because it seems better to have to wait in line than to have no health care insurance at all, which is what a large and growing number of Americans face every day. But after spending two years in the UK and meeting lots of people from countries with real health care systems instead of the crazy-quilt public/private patchwork we have here, I've realized that all those specters the insurance companies and Republican politicians held over our heads are just that: mere shadows. Yes, Virginia, you can run a government health care system that is clean, efficient, and gives patients plenty of choice. It's really not that complicated, but it can only be done when the people in government actually believe in its ability to help individuals -- rather than just treat it as a giant slush fund / goodie bag for well-connected political donors.

But at any rate, whatever you think about this new Medicare benefit or the merits of publicly provided health care, just don't give in to the soft bigotry of low expectations.