60 Years of Medicaid & Medicare: Health Care Challenges & Opportunities

Mark Masselli (00:04)
It is hard to imagine. But 60 years ago, only about 50% of elderly Americans had some type of hospital
insurance. but that all changed when President Johnson signed Medicare and Medicaid into law.

Mark Updegrove (00:17)
What Lyndon Johnson did, uniquely, perhaps not uniquely, but certainly distinctly, was he had this ability to
persuade. And so much of that came from what was Legendarily known as the Johnson treatment. Johnson had
an ability to get people, on his side by horse trading or cajoling or, or threatening or flattering, or whatever he
needed to do.

Margaret Flinter (00:41)
Our guest to discuss the 60th anniversary of Medicare and Medicaid is Mark Updegrove. He's the president and
CEO of the LBJ Foundation and the presidential historian for ABC News.

Mark U. (00:53)
You can learn a lot about who we are and where we're going by looking at our history.

Margaret (00:58)
This is Conversations on Healthcare.

Mark M. (01:11)
Well Mark Updegrove, welcome to Conversations on Healthcare.

Mark U. (01:14)
Thank you so much, Mark. Delighted to be here.

Mark M. (01:17)
Well, that's great. And let's just start off by asking you really to get in the way back machine back to 1965. What
was healthcare like for elderly Americans and, and how did they pay for it? And maybe talk a little bit about
how severe was the economic burden for seniors?

Mark U. (01:34)
Tremendously severe. In 1965, one third of America's population over 65 lived in poverty. LBJ, among other
things, is known for the war on poverty. The, the war he waged on poverty in our nation. And, and one of those
things necessitated, ensuring that Americans who couldn't afford the most basic healthcare needs could do so
through an insurance policy, allowed through Medicare. And, so it's, it's something that Harry Truman had tried
to push up the hill, wasn't able to do so. John F. Kennedy did so as well. but Lyndon Johnson got it done in
1965, and it's been woven into the fabric of our country ever since.

Margaret (02:26)
Well, let's, set the scene by talking a little bit about what was happening in the country six decades ago. Those
were interesting times, just like these are interesting times. The US had just elected Lyndon Johnson as president
in his own right following John f Kennedy's assassination. he was really at the height of his political power in a
long political life. Tell us who was he at that point, as you've come to know and understand him through
history?

Mark U. (02:53)
You know, you're absolutely right. Margaret 1965 is the high tide of the Great Society and of the Johnson
Administration. he of course, takes over, as president in the wake of the assassination of John F. Kennedy on
November 22nd, 1963. He rides out that year as an accidental president, becomes elected in his own right, in
1964 with the largest electoral mandate in American history, 61% of the popular vote, rides into the White
House with this mandate, and he knows the ephemeral nature of political capital. So he uses 1965 to get as much
done as he possibly can. And during the course of that year, you see the creation of Head Start and Vista and the
Department of Housing and Urban Development, the National Endowment for the Humanities, the National
Endowment for the Arts, the Highway Beautification Act, the Clean Air Act, the Clean Water Act, the
Immigration Act, the most sweeping immigration reform in the history of our country, the Elementary and
Secondary Education Act, the Higher Education Act, the Voting Rights Act, and the creation of Medicare and
Medicaid. And that is one year of the Johnson presidency. It's stunning.

Mark M. (04:18)
Well, you know, Margaret, I had the chance to read Robert Caro's four books on Johnson and, and Mark, you
know, it's, he really was able to use his political strength, to push through so many things. But, in particular the
federal health insurance program, and that, as you said earlier, that was really a legacy that, others had tried to,
to get through. How did he do it?

Mark U. (04:45)
You know, I, let me just go back for a moment, and, and mention again that, that, that Truman had really pushed
hard for this. And I think you had, the resistance of the medical community that doctors in particular, they
thought they were gonna lose money if you went to a, a federal, you know, what they considered social
medicine. John F. Kennedy, the year of his death had a huge rally at, at Madison Square Garden to push for, for
Medicare. Lyndon Johnson did it for a number of reasons. Number one, he was a, he was a student of power. I,
I, I think he understood in intrinsically the way that power worked, and he could work on lawmakers in a way
that Harry Truman and John F. Kennedy could not. He just had this great ability to get things done. Number
two, I think it was an idea whose time had come. you had, two thirds majorities democratic majorities in, in both
the House and Senate, and there was this confluence of circumstance that the circumstances, rather, that made it
possible for progressive reform like that to go into place, despite the violent resistance of so many Republicans,
and including, a Republican named Ronald Reagan, who had yet to be the governor of California and president
of the United States, but was a very active voice in the Republican Party, and said that it would be the ruin of
America to see, something like Medicare and Medicaid go through. It would, it would lead to, to greater
socialism in our nation.

Margaret (06:15)
Well, major legislation like this that is durational, long-lasting, changes over time. When you look back to the,
the founding, the creation of Medicare and Medicaid, what did it look like compared to what it looks like today?

Mark U. (06:30)
Well, a lot smaller, but, but let me just say Margaret, that I mentioned those things that, that Lyndon Johnson
was able to do in 1965, I, I also mentioned the War on Poverty. That was one of his objectives. Another
objective was, was racial equality. and this is the guy who had pushed for the, the Civil Rights Act in 1964,
spent a great deal of political capital, get that through The Voting Rights Act, came, as I mentioned, in 1965.
But so much of Medicare at the time was to ensure greater equality in this country. There was, there was a, a
desegregation of hospitals that was embedded in the Medicare Act. black Americans had far less longevity than
white Americans, and the healthcare needs were so much greater, for people of color than they were for, white
people in this nation. So there were, there were those things that were, crucial to this as well. But the, the
Medicare and Medicaid, as any big legislation does it, it evolves through time. And so the Medicare and
Medicaid envisioned by and enacted by Lyndon Johnson, it became much greater through time as our needs as a
nation became greater.

Mark M. (07:43)
You know, I really want to pull up on that, that thought about evolving, because who would've thought back
then that Medicaid would loom so large in our country today? Right. 90, a hundred million Americans, 68 or so
on Medicare, still important, but you see this popularity of Medicaid, and it was, I don't, was it an afterthought?
How did, how did Medicaid get put into the Medicare bill?

Mark U. (08:08)
I think it was very much a product of the war on poverty. Mark, as I mentioned earlier, the, the heavy
concentration on the alleviation of poverty in our country, which was chronic, about between, a, a quarter and a,
a fifth and a quarter of Americans lived in poverty. And as I mentioned, a third of Americans over 65 lived in
poverty. That number was far greater for people of color. It was far greater for, for rural Americans. So you had
these major factors that had, Johnson not only concentrating on Medicare, but the, the, the Medicaid program,
which I don't think Harry Truman and John F. Kennedy had imagined quite to the degree that Lyndon Johnson
had.

Margaret (08:51)
Well, certainly all major legislation, has its fierce opponents. And, and these programs were no exception. you
called out Ronald Reagan a little while ago, and said that Ronald Reagan said that the Medicare idea would be a
step towards socialized, medicine, in this country.

LBJ Commercial (9:10)
On September 1st, 1964, Senator Barry M. Goldwater interrupted his vacation cruise and headed for shore in a
big hurry. Destination: Washington, DC. He arrived just in time to cast his vote. “No.” Then he turned around
and headed back. Senator Goldwater flew across the continent twice, almost 6,000 miles to vote against the
program of hospital insurance for older Americans. As he said in the Atlanta Constitution on January 26th,
1963. “I've got my own Medicare plan. I've got an intern or a son-in-law.” Flip answers do not solve the
problems of human beings. President Johnson wants a program of hospital insurance for older Americans. He is
determined to see this program passed in the next Congress vote for President Johnson on November 3rd. The
stakes are too high for you to stay home.

Margaret (10:09)
You know, historically we've seen continued attacks like this. How, how did he respond to that? Was it just
politically get the majority and push it through, or was there a reasoned argument that he was putting forth that
said, no, this is not socialized medicine. It's still private's still gonna be privatized? there was no call within, as I,
as I understand it, within the Medicare legislation to take control away from physicians. It was very much about
actually opening up an entire new kind of line of reimbursement for physicians and hospitals, wasn't it across
the country?

Mark U. (10:44)
That, That's exactly right, Margaret. So there's a lot of education as there is with any big bill that's
transformational. You have to educate lawmakers, you have to educate lobbyists, you have to educate
constituents. And I think there was a concerted effort to do that. There, there was also, actions on the other side
to do the, the same thing. You had doctors' wives, holding coffees and playing records of, of Ronald Reagan as,
as I mentioned earlier, talking about what an evil Medicare would be and how it would lead to, socialism in, in
our country. So you had, educational efforts and propaganda efforts on both sides. But I think what Lyndon
Johnson did uniquely, perhaps not uniquely, but certainly distinctly, was he had this ability to persuade. And so
much of that came from what was legendarily known as the Johnson treatment. Johnson had an ability to get
people, on his side by horse trading or cajoling or, or threatening or flattering or whatever he needed to do to get
something over the, the, the finish line. And he had an uncanny ability to do that, which, which explains the
litany of transformational legislation that I enumerated a moment ago.

Mark M. (12:01)
He would physically get in people's space as well. So he used…

Margaret (12:05)
He was big.

Mark M. (12:06)
He, he was big. He would use many, many tactics, you know, you know, talked a little bit about the, sort of, the
opponents have really tried to shape the debate over time, really claiming the program will lead to sort of
economic disaster. And we've heard from the American Enterprise Institute, their projections, really at the turn
of the century, 1999, that Medicare would reach insolvency in the next two decades. I think that's, been trotted
out for many decades. that didn't happen. is it in part, just because of how popular it is and that Congress is
always gonna find a way to keep this afloat?

Mark U. (12:47)
I think that's right. And there's the, the concern among Republicans about big government, that's always been a
plank in the party. That's always been something that, that they have, beat the drum on reducing the size of
government. It's, it's, it's ironic because you see with the so-called big, beautiful bill that it makes our
government in some ways much bigger, may certainly makes our debt much bigger. and it cuts Medicare and
Medicaid substantially while giving the wealthiest Americans a major tax cut. So it is in some ways antithetical,
but, and, and paradoxical. But, I, I, I think once again, we see those programs, Medicare and Medicaid under
siege.

Margaret (13:34)
You know, if I, think back to the Affordable Care Act, run up summers, remember all the town halls with
seniors, with their, their placards. You know, no, no government health insurance. Keep your hands off by
Medicare. Medicare had had come to be seen as the private insurance, and a really, positive benefit like getting
social security. interestingly, we've never seen that kind of public support from all people for Medicaid, right.
Medic Medicare, it's like hands off. Medicaid still remains unequal among the states. do you think that, was

something that would've, surprised or disappointed Johnson to look across the states and see how much
variation there is based on where you live in this country? Your access to Medicare is pretty much the same,
assuming you have providers. But your access to Medicaid is not the same. There's been a different level of state
intervention. What, what would he have made of that, do you think?

Mark U. (14:31)
I think surprised, no, Margaret, but disappointed, yes. Surprised, no, 'cause you were seeing the same thing
really, related to civil rights in particular. Look at, you know, segregation at the time you had the, the deep
South, which was behaving very differently from other states. And so, so there was a certain, certain sectional
differences, but disappointed, yes. Because there are a lot of people who could benefit from Medicaid. And, for
instance, in Texas where I, I live and where I work, we have a, a, a government that has refused Medicaid to the
detriment of many of its poorest citizens. So, Johnson and Texan certainly would've been disappointed by that
as well.

Mark M. (15:13)
What Do, what do you think about that? Because, you know, Texas is a great example. I think there are
murdered only 10 states that haven't, signed up for the ACA Florida and Texas being the two biggest ones. But
Mark, probably 10, 20 billion dollars lost for the hospital system, the private providers, in the state. And then as
you looked at the sort of assault on Medicaid, now, there has been some really interesting congressional district
by congressional district of the percentage of Medicaid people. And you look at some of these much poorer
states from West Virginia's SWAT on down through the South, where there's, you know, huge amounts of
dollars coming into their state. And obviously people in need. What do, what do you make of what, why there's
a disconnect, in the minds of, the people who are opposed to that? In many cases, Republicans, it sort of doesn't
make a lot of sense. They're not voting their self-interest. this, this isn't the small proportion that happened in, in
the late sixties, early seventies, in terms of Medicaid's impact. This has been an enormous sea change.

Mark U. (16:22)
You know, I think a lot of it's our information ecosystem, which I think is the longest, or, or, or the, the biggest
long-term threat to our democracy. you know, there, there is this conservative media ecosystem where, you
know, the, the, the, audiences are being served up, misinformation, disinformation, relating to the federal
government, which has been vilified and demonized. A big government has been attacked. And, whether it is
beneficial to the, the, the folks who are consuming those programs or not, and I think a lot of people are because
of that misinformation and disinformation, again, to your point, Mark, voting against their own interests, that's
nothing new. But given the fact that there's such a, a, a fragmented, media landscape, I think the ability to
purvey, to serve up, misinformation and disinformation is much greater.

Mark M. (17:21)
I think they had some, some realization because in the bill, they pushed all the cuts past the midterm elections,
right? Most people were asking, I know we get asked all the time, Margaret, how's the organization could be
impacted by the Medicaid cuts? And I gotta remind them and say, it really happens in January, 2027…

Margaret (17:40)
After midterm.

Mark M. (17:41)
…a little after the midterms.

Mark U. (17:43)
That's right. That's exactly right. And, and of course, the timing of that is not coincidental. Right, right, right. so
it's, it's unfortunate. And again, I look at the, the media landscape as a major culprit here as well.

Margaret (17:57)
You know, it's, it's so great to have a chance to talk to you with your depth of knowledge of this period in time
when all this was happening. And though I hadn't planned on it, let me take the opportunity to ask you. It's this
time of the signing 1968. It's also the really the time of the creation of the community health centers in the
United States, the beginning of the movement, which we've been part of for, half a century. Sergeant Shriver
authorizes some of the OEO, demonstration projects and the statute, that ultimately created, community health
centers get signed into law. Do you think that figured anywhere in his thinking as well, that there needed to be a
delivery system to make sure that poor people in particular had access to healthcare? Or was that all being

handled by other people and he was razor focused on, on the Medicare and Medicaid bills at large? Just curious
if you have any insights into that.

Mark U. (18;52)
No, I think this is part of LBJ's sweeping vision for a better America. I mean, all this stuff was interwoven. you
know, we, we, we tend to look at the great society in different categories. There's healthcare and there's
education, and there's immigration and civil rights and poverty alleviation. But ultimately, if you look at the
legislation itself, and I alluded to this with, with Medicare a moment ago, all this stuff is interwoven. Right.
There's a major poverty component in Medicare. There's a major race component in Medicare, but there's a
major education component.

Margaret (19:28)
Exactly. Another big piece of it.

Mark U. (19:32)
Right. So he's thinking in a big way about all this stuff.

Margaret (19:37)
Bring him back!

Mark U. (19:38)
…and it factors into the legislation. Right? Right? Yeah. Yeah.

Mark M. (19:42)
Well, and, and, and I think, someone who spoke, truth to power all the time, he, he was a real champion. So
many things, such a consequential president. And we shouldn't forget that, in 1965, President Johnson also
signed the Older Americans Act into law. maybe talk a little bit about what the law covered and how does it
affect the health of seniors today?

Mark U. (20:09)
You know, so Medicare was part of it, right? Ensuring that the, that the, older Americans who couldn't afford it
could have the most basic healthcare needs met, but there were other, needs that older Americans had that, that
weren't embedded in, in Medicare. So, there were a number of measures that he took to ensure that older
Americans were being thought of, that we were thinking about, the elderly community, you know, there was, he,
he used to talk about LBJ, that when he was young, people would go over to the poor house. And effectively
what that meant was that there was an older member of a household who had healthcare needs that weren't being
met, and they would essentially send them someplace to die. That was almost a dying center. Right. it was
hospice care before that term was readily known. And, so he saw many people going over to the poor house
because they couldn't afford to be tended to. And so, the, the, the, the aim of his administrator, or the aim of
these efforts around the elderly Americans were not just about healthcare, but other aspects of tending to our
elderly and in, in the American, you know, throughout America.

Margaret (21:30)
That expression of the poor house and remember growing up. Yeah. You know…

Mark U. (21:35)
You all heard that. And I think that that term, to some degree evolved. But at the time, it was about very,
something very specific. It was a euphemism for essentially sending an, an elderly member of your family out to
die.

Margaret (21:51)
Well, you recently released a new book titled “Make Your Mark: Lessons and Character from Seven Presidents”
and it includes a chapter about George W. Bush's work to start the PEPFAR program, which provides as, we all
know HIV/AIDS prevention and treatment and care, to people in developing countries. Tell us so much out
there, why did you pick this topic to include, and what lessons should we take from this section?

Mark U. (22:16)
You know, the, the, the, the Greeks said, 2,500 years ago, the character was destiny. And I think that sentiment
rings as true today as it ever has. And, and it's particularly true in our leadership. We need character in our
leaders to ensure that we are on the right course character's the rudder that directs a leader's actions, and

decisions. And, and we're not seeing it in, in my personal view, we're not seeing a great deal of character from,
we're certainly not seeing a great deal of compassion from our president today. But the, the quality that I
highlighted for George Walker Bush is about giving back. And, and that is very much instilled in the, the ethos
of the, the Bush family. You've, you've, you've had a good in this country and, and there's the biblical proverb
that, George W. Bush adhered to, to whom much is given, much is required. And during the, the beginning part
of the millennium AIDS epidemic was ravaging much of the world, including in particular Sub-Saharan Africa,
where it threatened to wipe out certain sects of the, the, the population. And Bush realized he could do
something about it. and that, led to the creation of PEPFAR, the President's Emergency Plan for AIDS Relief,
which since it, it went into place in 2003, has saved the lives of over 28 million citizens of the world. That's
more than the population of Australia for a relatively minimal investment. So that's a great example of, giving
back. And, and it's something that we should be aware of, something that, that, that we should be proud of and
should con continue to sustain.

Mark M. (24:11)
Margaret, you remember last year we were at Aspen Institute, had the opportunity to sit with Tony Fauci on the
anniversary of PEPFAR. And, he, he told a great story about w in terms of, he got him in his office. He said,
you know, what do you think this is gonna cost? And he, and, and Tony sort of used a little number. He said,
you know, Tony, you go over to Africa and figure out if we can solve this problem, let me worry about the
money. So he was really very committed to this. Didn't matter the size, you just knew the importance of it. And
I'd also say probably surprising on the community health center world, he was a big supporter. which, you
know, sort of came out of the blue for many people in the movement. but he was also realized and probably,
just, growing up, in, in Texas and, and realizing the importance of, of taking care of the people who, who you,
who you represent. So character really mattered, and we saw a lot of that, in, in his actions. You know, Mark,
you've had a varied career including leadership roles in media. Why is presidential history so important to you,
and why do you think it matters?

Mark U. (25:25)
You know, I, I was, as it happens, Mark, I was at the Harry Truman Library yesterday in Independence,
Missouri, right outside of Kansas City. and Harry Truman, said something, which I've quoted off, and he said,
the only thing new in the world is the history. You don't know. And you can learn a lot about who we are and
where we're going by looking at our history. and so I, I, I think it's, you could, you can see it in particular, in our
presidential history. Again, because of the character of our leaders, we've seen our country steered in certain
directions, making certain pivotal district, decisions, based on, the American values that, that we, represent that,
that, that America is known for. So I think, the, the history has always been of great interest to me, and I think to
a large extent, we can see our future by looking at our past.

Mark M. (26:25)
You know, you talked about a, a moment we're pivoting now, and I'm wondering, is there anything from the
Johnson history in terms of how we bring people back together? certainly there's been a fragmentation, that's
existed in the political landscape. what's The, what's the local anecdote to what may be, you know, very rough
winds coming out of Washington?

Mark U. (26:51)
Well, there are two things. One, one of the things that, that folks I think should know is that, you know, the,
those programs, I enumerated the, the, the, the 1965 legislation, that's just 1965. But if you look at the, the, the
accomplishments of the Great Society, they're much greater than that. That's the high tide of the Great Society.
But they, they go on and on and, and we hear about the eradication of government from the, the Trump
administration. and he's often, vilifies Joe Biden or Barack Obama, or Bill Clinton, even George W. Bush. But
at the end of the day, the here eradication of government is principally about the, the, the, the, the, the,
elimination of a lot of the programs that came in The Great Society. That's what's at stake here. The Great
Society was in large measure, the, the foundation of Modern America. So much that has been woven into the
fabric of our, our nation was in those, that, that legislation that, that I mentioned, I think LBJ had a, a, a, a phrase
that I loved. He used to invoke, a phrase that was, that, that he had learned in his youth. And that is, “Any
jackass can kick down a barn door, but it takes a damn fine carpenter to build one.” And I think what you see
singularly throughout the Johnson administrations is effort to build a better America. Some things succeeded,
some things failed. But we did become, I think, ultimately a better country because of the things that were
enacted in the 1960s. I see a lot of destruction today. I see a lot of the, the tearing down of things, but I don't see
a vision for what we can build in place for toward a better America. And that's something I'd like to see in the,
in the days, months, and years ahead.

Margaret (28:42)
As would we mark up to Grove. Thank you so much for joining us today on Conversations on Healthcare, and
thanks to our audience for being here. Just a reminder to subscribe to our videos on YouTube, find us on
Facebook and X, and share your thoughts and comments about this program. We love to hear from you.
Take care and be well.

(29:03)
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