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Improve Medicare and Expand It to All

Jim Recht

In honor of its 46th birthday this month, here is a brief history of Medicare: of the bitter controversy surrounding its creation, its subsequent achievements, and its current position at the center of congressional budget debates. I believe that once they understand the deep differences between this institution and our country’s more recent attempts at healthcare reform, most reasonable individuals will conclude that a national insurance system like Medicare offers a solution to the healthcare crisis, and that it should be fully funded and extended to cover all Americans from birth.

During the contentious debate that preceded its adoption in 1965, Medicare was attacked by powerful special interests -- among them, the insurance industry and the American Medical Association -- who decried it as "socialized medicine" and warned that it would destroy our healthcare system and even threaten our basic freedoms. It seems difficult today to imagine how such fear-mongering could have been taken seriously. Over the past half-century, by affording hundreds of millions of Americans access to high-quality health care, Medicare has played a major role in increasing life expectancy and overall quality of life in this country. Funded via a progressive tax mechanism that asks incrementally more of our wealthiest neighbors, and boasting better service and far lower administrative costs than the "leanest" private insurance, Medicare has become along with Social Security one of the most popular government programs in history.

In his speech announcing the new plan, then-President Johnson reminded the country that "there is a tradition we share today. It calls upon us never to be indifferent toward despair. It directs us never to ignore or to spurn those who suffer untended...[it] is as old as the day it was first commanded: 'Thou shalt open thine hand wide unto thy brother, to thy poor, to thy needy, in thy land.'"

The current administration's health reform legislation, and our own Massachusetts Health Reform that preceded and inspired it, are part of a very different story. That one begins in 2006 when, largely in response to Bush Administration pressure, then-Governor Mitt Romney signed into law legislation that dismantled our extensive healthcare safety net, partially replacing it with an “ownership culture" that has required hundreds of thousands of low- and middle-income residents to purchase insurance policies sold by private corporations through a state-run exchange.


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5 years on now, despite our mainstream media's oddly strained attempts to suggest otherwise, we face overwhelming evidence that the Massachusetts Reform has failed. According to the comprehensive report released this month by Mass Care (, Massachusetts reform has certainly forced many more Massachusetts residents to purchase health insurance policies – a boon to insurance companies, whose revenues have increased dramatically. But the difference between having insurance and having adequate access to quality healthcare has grown more oppressive than ever. For most individuals and families except for the very poorest and the wealthiest, out-of-pocket payments and insurance premiums have continued to skyrocket. Wait times for primary care appointments have increased, while ever fewer primary care doctors accept new patients -- they simply cannot cope with the administrative costs and frustrations of a system dominated by private insurance companies, each with its own system of authorizations, denials and appeals. Finally, with state spending continuing to increase at alarming rates, it is now beyond question that the reform is financially unsustainable.

And now that the entire country has adopted legislation largely patterned on the Massachusetts reform, we brace ourselves for similar or worse developments on a national scale: increasingly unaffordable or unavailable medical services, runaway profits for insurance companies, and continued spikes in overall costs. Adding insult to injury, some politicians have proposed balancing these tremendous public losses by cutting Medicare benefits. Fortunately, Americans strongly oppose such measures; recognizing this, one prominent Tea Party leader has dismissed them as a "public policy nightmare.”

Rather than weakening Medicare, we ought to build on its strengths and correct its flaws:

  • By replacing the current physician fee schedule with a system of negotiated payments, we can eliminate the critical shortages of skilled primary care providers and encourage the type of integrated practice exemplified by the Mayo Clinic and others;
  • By instituting global budgets, we can avoid wasteful duplication of high-cost technology and fully fund the clinical services that we, as patients, want and need;
  • By legislating price negotiating authority and bulk purchasing power for pharmaceuticals and medical devices, we can immediately begin saving taxpayers hundreds of billions of dollars annually.

This improved-and-expanded Medicare would simultaneously eliminate "mandates" and corporate profiteering.  In consequence, the billions we already spend each year would be more than enough to provide excellent healthcare automatically to everyone who needs it. A sustainable system that actually reduces our anxiety over the healthcare of ourselves and our children: now who wouldn't appreciate a birthday gift like that?

Jim Recht, MD is a psychiatrist living and working in Cambridge, Massachusetts. He is also Massachusetts chapter co-chair of Physicians for a National Health Program.

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