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Medicare, Medicaid may paint health care's future Programs' revisions hint what's next for Affordable Care Act

Capital (Annapolis, MD) - 7/30/2015

WASHINGTON - Half a century after President Lyndon Johnson signed legislation creating Medicare and Medicaid with a pledge that seniors no longer would "be denied the healing miracle of modern medicine," that promise has been largely fulfilled.

The two entitlements - one for the elderly and one for low- income Americans - have kept generations of seniors in their homes and extended life-saving insurance protections to poor children and families. The share of uninsured seniors, which was 48 percent in 1962, is now less than 2 percent.

Yet, the two programs today look far different than they did in 1965, as Democrats and Republicans have each expanded and reshaped them over the last five decades.

The evolution has been at times contentious, and often unexpected, with GOP presidents presiding over some of the biggest expansions.

That history may offer clues about what lies ahead for the sweeping, deeply polarizing health law that President Barack Obama enacted in 2010.

"It will be very hard to pick apart the Affordable Care Act," said Commonwealth Fund President Dr. David Blumenthal, who has written extensively on America's health care history. "But I expect there will be efforts to reduce its scope and to expand it. ... That tension will shape the law for generations to come."

Not unlike the 2010 law, Medicare and Medicaid were the products of yearslong political battles, intense industry lobbying and hyperbolic rhetoric.

To mollify opponents, the architects of Medicare and Medicaid - which were signed into law July 30, 1965 - deliberately limited the two programs at first.

Medicare, for example, didn't cover prescription drugs. It didn't even set medical fees, allowing physicians to set their own rates. For its part, Medicaid, which was run by states, was initially envisioned only as coverage for very low-income mothers and children receiving cash welfare.

And federal lawmakers gave states broad discretion on whether to even set up a program. (It wasn't until 1982 that all 50 states adopted Medicaid.)

"For years, it was a poor program for poor people," said Columbia University's Michael Sparer, a leading Medicaid scholar. "It was really an afterthought."

It didn't remain so. Medicaid, which covered fewer than 20 million people in 1970, now insures close to 70 million, as state and federal officials from both political parties collaborated over the years to steadily make more Americans eligible.

Through the '80s, for example, Southern governors who were worried about high infant mortality rates pushed Democrats and Republicans in Washington to bring pregnant women and more children into the program.

In the '90s, children from working-class families were brought into government coverage as President Bill Clinton, a Democrat, and congressional Republicans created the State Children's Health Insurance Program.

Medicare, which now covers about 55 million people, has added new groups too, including Americans with disabilities.

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