The Struggle for the Soul of Medicare

Not so very long ago - in historical terms - the politics of Medicare were thought to be stable and well-established. Medicare’s 1965 enactment culminated an epochal political battle that spanned fifteen years and involved mass mobilization, millions of dollars in lobbying expenditures (including the development of such techniques as “grass-roots lobbying” and targeted direct mail), and bitter partisan controversy. By the late 1980s those seemed to be distant birthing pains long since overshadowed by the program’s robust health and popularity. Medicare politics had devolved into a model of pluralist “normalcy” in which a relatively specialized and autonomous group of subject-matter experts in the federal bureaucracy, the Congress, and affected interest groups largely made policy by negotiating among themselves, primarily on issues of provider reimbursement. Even the extraordinary events involving the 1988 enactment of the “Medicare Catastrophic Coverage Act” legislation (which, among other things, established good coverage for prescription drugs), and the ensuing public firestorm that led to its partial repeal in 1989, could be seen as an aberrational deviation from a more placid pattern.