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Compromise 5: Medicare’s Complicated Birth

May 2024
3min read

LBJ passes comprehensive federal insurance for seniors with shrewd politics and a strong dose of compromise

In 1965, after winning in a landslide against Barry Goldwater and helping to carry Democratic supermajorities into both houses of Congress, President Lyndon Johnson set out to enact a battery of Great Society reforms, including Medicare, government insurance for seniors. Despite his political mandate, 60 years of conservative opposition to such a measure meant proceeding with caution. Later, California Governor Ronald Reagan, for example, would characterize the Medicare bill as the advance wave of a socialism that would “invade every area of freedom in this country.” Reagan predicted that this reform would compel Americans to spend their “sunset years telling our children and our grandchildren what it was like in America when men were free.”

With 63 percent of Americans favoring passage of Medicare, Johnson believed that diehard conservative Democrats such as Wilbur Mills, the chairman of the House Ways and Means Committee, who had repeatedly blocked a Medicare bill from reaching the House floor, would be hard-pressed to maintain his opposition. Johnson had little leverage over Mills, who had a safe seat and feared that Medicare would bring fiscal disaster upon the country. Privately, Johnson complained that Mills was a “prissy, prim, and proper man . . . [who] was afraid to put his reputation behind a risky bill.”

Johnson’s accute political instincts told him that—even with popular support for Medicare pressuring the congressman—he would do better to place a compromise bill before Mills’s committee rather than one that would provoke the gentleman from Arkansas into bitter opposition. To combat charges of socialized medicine and signal his desire to reach an accommodation with the opponents of his initiative, Johnson advanced a limited bill that covered only hospital costs for seniors through expanded social security. He omitted coverage for doctors’ fees, aware that by doing so he could avoid charges of introducing a British-style national health care system by creating a new class of fee-compensated government employees.

Ironically, when the opposition tried to sidetrack Johnson’s reform by proposing “Bettercare” and “Eldercare,” bills that would cover only the indigent for both hospital and doctors’ costs through government-subsidized private insurance, Johnson expanded his original proposal to include physicians’ costs, determined not to let the other side outdo him. He accurately saw the conservative proposals as a giveaway to the insurance industry, which would leave elderly citizens who were above the poverty line uncovered.

Johnson called Senate leaders to the White House in front of TV cameras to discuss the prospects for the legislation. This tactic forced Harry Byrd Sr., chairman of the Finance Committee and another longstanding opponent of Medicare, to make a public commitment to prompt action by his committee. As Johnson understood, the changed political climate and moderate proposal he had put before Congress had made all the difference in compelling Byrd to accept what he no longer could stigmatize as a radical reform.

But even after Johnson had disarmed Mills and Byrd, he felt compelled to corral every possible vote by instructing his aides to treat all members of Congress as if they were president. A call from a senator or a congressman had to be answered in “10 minutes or else!” Johnson instructed aides to tell members of both parties what a historic contribution they would be making to Americans’ well-being. He wanted all members of Congress to think that, if they voted for his education and Medicare bills, their grandchildren were going to say, “My grandpa was in the Congress that enacted these two.”

Even after Medicare passed, Johnson was not content. He wanted the American Medical Association, which had close to a hundred lobbyists in Chicago and Washington battling the law, to give their support to its implementation. Johnson invited the association’s principal officers to the White House; but instead of talking about Medicare, he entreated the doctors to recruit physicians to help the civilian population of Vietnam. “Your country needs your help. Your president needs your help,” he implored them. The doctors responded, almost in unison, with promises to start a program. “Get the press in here,” Johnson told his press secretary. Having been put on notice that they would be invited and no doubt encouraged to ask the doctors if they would support Medicare, the journalists listened as Johnson praised the AMA leaders for their patriotism.

The reporters at once skipped over the Vietnam program and asked the doctors about their position on Medicare. Johnson, with mock indignation, said: “These men are going to get doctors to go to Vietnam where they might be killed. Medicare is the law of the land. Of course, they’ll support the law of the land. Tell them,” Johnson instructed, turning to the president of the AMA, who obediently responded, “Of course, we will. . . . We have every intention of obeying the new law.”

The master legislator, seizing upon changed circumstances and his commitment to what was now perceived as a moderate, less radical law, won passage and support for a program that had been on hold since the beginning of the 20th century. It represented a victory not only for seniors and their families eager for insurance against financial ruin but also for the tradition of rational political compromise and the rule of law.


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