The Fierce Urgency of Now

by Julian E. Zelizer

  The tide had turned since November. The issue was no longer whether there would be a health-care program but which health-care program there would be. Wilbur Cohen, the assistant secretary of health, education, and welfare, acknowledged that John Byrnes’s Bettercare proposal provided generous benefits under a voluntary program that did not depend on Social Security taxes. The bill had real support in Ways and Means, enough to threaten the passage of King-Anderson. President Johnson remained focused on pushing Medicare through the Ways and Means Committee. He mulled over with his advisers and some legislators the idea of a combination of programs, and he always recognized that he would have to give Mills credit for any change.59 As he had told Wilbur Cohen, “You get him [Mills] something, though . . . if labor will buy, that he can call a Mills bill, that’s what it amounts to, and you’re smart enough to do that.”60 Most important, Mills himself had been talking with Johnson’s team for more than a year about the potential for some kind of combination that included physicians’ costs and an expansion of Kerr-Mills.61

  Wilbur Mills knew there was enough support in his committee and in the House to pass the administration’s Medicare proposal, and rather than try to block the train, he decided to climb on board. On March 2, after weeks of closed-door sessions, the chairman surprised most of the participants in the committee room with a bold move that reframed the entire debate. They had spent the afternoon reviewing Byrnes’s plan, which Wilbur Cohen and the Social Security actuary Robert Myers admitted was financially sound. Other Democrats who backed Medicare, among them Representative Eugene Keogh of New York and Senator Jennings Randolph of West Virginia, observed the interaction with growing interest in the Republican alternative. Mills too grasped that Byrnes’s program was sound. “You could see the light bulb flash on his mind,” recounted one participant in the room.62

  Just moments into the session, after a year of discussions about this idea and that one, this bill and that one, this way of funding and that one, the chairman leaned back in his chair, looked at Wilbur Cohen, and said, “Well, now let’s see. Maybe it would be a good idea if we put all three of these bills together. You go back and work this out overnight and see what there is to this.” At a stroke, Mills had created a “three-layer-cake” that combined Medicare, Eldercare, and Bettercare into one big bill. “It was all over,” one committee member said. “The rest would be details. In thirty seconds, a $2 billion bill was launched, and the greatest departure in the social security laws in thirty years was brought about.”63 “The effect of this ingenious plan is, as Mr. Mills told me, to make it almost certain that nobody will vote against the bill when it comes on the floor of the House,” Cohen reported to the president. “It should be clear that Mr. Mills would retain all the basic elements of the King-Anderson program financed through social security but add to the bill a supplemental health insurance benefit which many aged people would be willing to purchase because the Government would subsidize out of general revenues some portion of its cost . . . I feel reasonably sure that now after these several weeks of Committee sessions Mills now feels he has developed a combined package approach which is unassailable politically from any serious Republican attack.”64 All that remained to be achieved was a final version, the approval of both chambers of Congress, and the signature of Lyndon Johnson.

  Over a period of three months, Wilbur Mills had transformed himself from the chief opponent to the architect of the new law. Combining the three bills had resolved the fiscal and political concerns that had prevented Mills from signing on. The new plan kept the costs of physicians separate from the portion of the program that was funded by Social Security taxes. Hospital stays would be covered by Social Security taxes. All seniors would have to enroll in the hospital program, but insurance for doctor bills would be voluntary; it would be covered by income tax revenue and monthly payments from participants. The bill seemed politically invincible. Cohen explained, “In effect, Mills had taken the AMA’s ammunition, put it in the Republicans’ gun, and blown both of them off the map.”65

  Mills and the administration had evidence that public opinion was on their side. According to Louis Harris, a majority of Americans supported health-care insurance for the elderly. When given a choice between a program that was funded by the federal government and one that was privately financed, the public supported a government plan by four to three.66

  Mills knew he needed to move swiftly to prevent opposition from coalescing. His staff and the administration staff would have to finish the final legislation in time for the committee vote he announced for March 15. The schedule offered staffs only thirteen days to draft what would be an enormous bill.67 Ironically, Mills could speed up the drafting because he had slowed it down for so long. All the key players from the Social Security Administration and the Ways and Means Committee staff were so familiar with every detail of the various bills, after years of negotiations, that they were prepared to work at great speed to finish a new version in executive session.

  Johnson was surprised by what Mills had wrought. In a revealing phone conversation with Wilbur Cohen after the announcement of the three-layer cake, Johnson asked many questions about the details of the legislation. Cohen walked him through a number of key provisions.68

  The legislation carried in the committee on a straight party vote, 17 to 8, with Republicans voting in favor of John Byrnes’s proposal, which they were still not ready to abandon, even though it seemed to most observers that Mills’s version would win the day. Mills was the hero. When he walked down to the well of the House to introduce the bill, his colleagues stood and applauded. On April 8, the House of Representatives passed the Social Security Amendments of 1965 by 313 to 115. Fifty-nine southern Democrats and 65 Republicans—who joined 189 northern Democrats in the majority—had broken from the conservative coalition. The minority was the remainder of the conservative coalition; it included 40 southern Democrats and 73 Republicans as well as two northern Democrats. The actual vote was not as bipartisan as it appeared in the end. Before the final vote, Republicans had used a technical procedure to allow the House to get a vote on an alternative based on the Byrnes bill. Although that vote failed, it did so narrowly, by 236 to 191, with 128 out of 138 Republicans in favor of the Byrnes substitute.69

  Part A of the Social Security Amendments offered federal health insurance for hospitalization costs to people sixty-five and over, paid for by Social Security taxes. Part B provided voluntary insurance for the cost of physicians’ services, paid for by a combination of monthly contributions from participants and federal contributions from general revenue. Part C of the legislation, Medicaid, expanded Kerr-Mills with a larger means-tested program for people in the existing welfare categories—aid to the elderly, aid to the permanently and totally disabled, aid to families with dependent children, and aid to the blind—that was administered by the states and paid for by state and federal money.

  The American Medical Association was resigned to defeat. The tempered mood in the physicians’ community was clear when, while the Senate deliberated, twenty-four thousand or so doctors arrived in New York City to attend the association’s 114th annual convention. The House of Delegates, its decision-making body, ignored calls by some state chapters that the AMA tell its doctors they should refuse to accept patients whose bills would be covered by the program. Instead, the House of Delegates took the position that individual physicians had the ultimate right to determine whether a program was good for the quality of health care. The new president of the association, James Appel, a fifty-eight-year-old surgeon from rural Pennsylvania who staunchly opposed Medicare, made an appeal in his inaugural address to fellow physicians to reject boycott proposals, which he said would set poor examples of citizenship. He warned that “unethical tactics”—boycotts or strikes against Medicare—would result in Congress’s passing even more stringent federal regulations. “We do not have the right, either as physicians or citizens, to deliberately violate a law, or to v
iolate the spirit of the law or its intent.”70

  Now all that stood between America and Medicare were fifty-one votes the White House needed to get in the Senate. The administration did not anticipate a filibuster.71 Conservatives were in no shape to mount one, and Republicans had little interest in joining one. Mills, one of the most powerful southern Democrats, had designed the legislation, and it was likely that others from the region would support his bill.

  The real risk for Johnson came from liberals. He needed to make certain that liberal Democrats in the Senate did not undo Mills’s compromise by increasing the cost of the bill in any significant way. Mills would not accept any additional strains on the Social Security tax. He had a winning bill in hand and did not want to give the bill’s flailing opponents an argument they could use to weaken support on the floor. President Johnson also wanted a bipartisan vote of confidence in this historic expansion of the role of government so that it couldn’t be attacked down the line as a “Democratic bill.”

  There were efforts to liberalize the bill in the Senate. Though every Democrat understood the risks of adding amendments, in the post-1964 atmosphere some senators refused to be constrained by the traditional pragmatic warnings from their colleagues. A substantial number of amendments from liberal Democrats made it into the final package.

  The total cost of the Senate bill was approximately $800 million more than the House bill, enough to raise serious concerns in the White House about what Mills’s response would be and whether this cost inflation would jeopardize bipartisan support in the House. On July 9, the Senate passed the legislation, 68 to 21.

  During the conference committee, Mills came to the rescue of the version he had crafted in the House. His power as the chairman of Ways and Means enabled him to dominate the conference committee deliberations in a ruthless fashion. Legislators were not about to challenge him, nor were administration officials, who would need Mills on other measures and didn’t want to give any hint of a desire to try rolling over the chairman. When senators in the committee saw that Wilbur Cohen, Johnson’s point man on Social Security and Medicare and the administration’s representative in the conference committee deliberations, was standing behind Mills, they realized there was no point in pushing for the liberalizations that had been included in the Senate version. Senators Russell Long, the majority whip, and Florida’s George Smathers, one of Johnson’s closest friends in the Senate, also allied with Mills to push back against their colleagues at this point. In the closed room of the committee, shrouded by secrecy, without interest groups or reporters present, a hallmark of this insular era in congressional politics, and with most members deferring to his expertise, Mills systematically knocked out almost every Senate amendment that increased costs, and he shifted specialist services from the mandatory to the voluntary section of the program, thus protecting the Social Security tax and reducing the number of doctors who could complain that they were included in the mandatory program. Larry O’Brien said, “There was nobody in that conference who was going to buck Wilbur Mills on the House side and probably there was little appetite to buck him on the Senate side either.”72

  Medicare did not pose any genuine threat to the private health- care system, despite all the overblown rhetoric of the AMA,73 but in an effort to design the program in such a way that physicians would buy into it and to further undercut lingering claims that the program would “control” the medical industry, Mills made one decision that would eventually result in exploding costs for the program. He demanded that the law authorize hospitals and doctors, rather than the federal government, to determine what “reasonable charges” should be for their services. He made this move based on the mistaken assumption that it would not result in any huge increases in the costs. Johnson accepted Mills’s proposal on the same grounds.

  On July 27, the Senate passed the conference committee measure by 70 to 24 and the House by 307 to 116.

  Before signing the bill, Johnson wanted to make sure that doctors were fully on board. In late June, he had invited AMA representatives to attend a meeting at the White House. He began by asking if they would agree to send volunteers to help care for soldiers in Vietnam. The delegation said yes. After expressing his appreciation to the group, the president then asked the White House press corps to question the delegates about their Vietnam commitment. When one reporter asked a question many suspected had been planted by the White House—Was the AMA going to boycott Medicare?—Lyndon Johnson interrupted to say, “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.” Looking at the president of the AMA, James Appel, Johnson said, “Tell him.” Appel, realizing that he had been put on the spot, said, “We are, after all, law abiding citizens, and we have every intention of obeying the new law.”74

  On July 30, the president traveled to Independence, Missouri, to sign the legislation at the library of Harry Truman’s presidential museum. Truman, eighty-one years of age and still scarred from the hell the AMA had given him over his health-care plan in 1949 and 1950—it slammed the proposal as a “monstrosity of Bolshevik bureaucracy”—sat proudly by Johnson’s side during the ceremony. More than two hundred people, including thirty-one members of Congress and Vice President Humphrey, were packed into the room to watch. The legislation was a key moment for the Great Society and for American health-care policy. For decades, politicians had unsuccessfully fought to have the federal government provide health insurance. As a result, the federal government had remained a minor, usually inconsequential player in the health-care system. But now, after what had happened in the closed rooms of Ways and Means, things would be different. The federal government would be the insurer of first resort for the nation’s elderly and indigent citizens. The right to health care for the elderly and the poor had been enshrined through the Great Society.

  There was plenty for liberals to be disappointed about. The legislation was a far cry from the program President Truman had proposed. It created a two-tiered structure that provided federal support only to a segment of the population. Congress had also rejected any cost controls for hospitals and doctors.75

  Yet most liberals were extremely pleased with the outcome. They understood that the program was a huge step forward in creating a social safety net. It would guarantee that most elderly citizens no longer had to fear they would be unable to pay for hospitals and doctors. Liberals also believed that more was coming. They saw Medicare as an opening wedge for the government to expand its role in the health-care system, eventually bring more groups under its coverage, and ultimately establish a universal program. As Robert Ball, another key figure in the Social Security Administration, later said, “We all saw insurance for the elderly as a fallback position, which we advocated solely because it seemed to have the best chance politically . . . We expected Medicare to be the first step toward universal national health insurance.”76

  ENSURING THE RIGHT TO VOTE

  The dramatic passage of the Civil Rights Act of 1964 had given civil rights leaders greater clout in Congress, and the liberal gains in the 1964 election, in which approximately 94 percent of registered African Americans voted for Johnson, had demonstrated that the movement could deliver votes. The activists were energized by their triumphs, and they pushed for a new civil rights bill that would give the federal government greater authority to enforce the Fifteenth Amendment, which made it illegal to deny anyone the right to vote based on “race, color, or previous condition of servitude.”

  After Reconstruction, the federal government did nothing to counteract the malicious effects of literacy tests, residency tests, and poll taxes that southern states passed to make voting extraordinarily difficult, if not impossible, for African Americans—and poor whites too, unless they were exempted by grandfather clauses. The number of African Americans registered to vote in southern states, where the great majority of the African American
population lived, remained small throughout the first half of the twentieth century. A mere 3 percent of the five million eligible southern African Americans were registered to vote when World War II began. For almost ninety years, Congress did little to rectify the situation. The Civil Rights Act of 1957 had been so watered down that it relied on local juries, on which only whites could serve, to enforce the voting rights of African Americans in the South. The civil rights legislation of 1960 granted local judges more power to register voters, but they were generally white segregationists who did little or nothing to expand the franchise.

  There had been some progress by the early 1960s, but it owed little to Congress. A coalition of civil rights organizations that included SNCC, SCLC, CORE, and the NAACP had established the Voter Registration Project, which provided money to grassroots activists who worked frenetically in southern states to help African Americans circumvent Jim Crow barriers and get registered. In 1964, there had been a higher turnout of African American voters in the South than in any previous presidential election, although almost 57 percent of the African American population there were still not registered to vote.

  The Supreme Court was also influential. Under the leadership of Chief Justice Earl Warren, the Court made a series of important rulings between 1962 and 1964 that established the one-man-one-vote rule for state and federal legislative elections. For decades, state legislatures had avoided redrawing voting district lines for U.S. House and state legislature seats, even though rural districts generally had declining or stagnant populations and urban districts were experiencing huge population growth. Many of the urban districts had heavy concentrations of African Americans and young liberal whites, while the rural districts were often all white and politically conservative. In their decisions, the Supreme Court required states to redraw legislative districts so that every voter had equal representation in legislatures.