We will never solve health care…

… if we don’t understand the roots of how we got to here. It’s very easy to use the words “Medicaid,” “Medicare,” “MinnesotaCare Buy-in” and “Obamacare” in a sentence, but how many of us know really know how and why these elements of our health care system were established?

Hi, my name is Kenza Hadj-Moussa, and I’m the new Communications Director at TakeAction. Everyone has a story about health care. And health care, as a social issue, has a story too. Here’s my take on the historical roots of our health care system, and why it’s so hard to fix it today [hint: it’s the biggest taboo subject in American politics]. Take a look and let me know, after reading this, what are you left with? Send us an email at info@takeactionminnesota.org.

In 1964, just 47 days after President Kennedy was assassinated, President Johnson gave his first State of the Union speech to a still-mourning nation. The nation was at war in Vietnam, though not at the level it would come to dominate in American culture. The U.S. never formally declared war on Vietnam, in fact, but LBJ did use his speech to declare war… an “unconditional war on poverty.” 

And a dark national secret was becoming exposed: America was poor. The post-world war, mid-century, Leave-it-to-Beaver economic boom that built America’s white, middle-class was over. From Detroit to rural Kentucky, Americans were hungry and suffering. Kennedy saw this firsthand during his many trips to West Virginia in 1960 ahead of his primary election win. 
 
For LBJ, using military terms to declare poverty as a war-like enemy made sense. Historically, poverty hasn’t been addressed out of the kindness of our hearts; it’s been addressed for national security reasons. Before the New Deal in the 1930s, officials were alarmed when sickly soldiers with skinny arms reported for military duty. How could wiry boys protect the country, fight fascism, or communism?
 
In 1964, just a year after the Cuban Missile Crisis, political moves were made to fight communism and to assert ourselves as the world’s leader. To be a superpower, the country had to be, well, super. This meant that we had to get it together on the home front: education, health care, wages, a trip to the moon!
 
President Johnson signed his Great Society package in a cool 18 months—the cold war was partly a race with Russia, and Congress hustled. 
 
In 1965, the federal government rolled out AmeriCorps VISTA, Head Start, and Community Action Programs. Congress invested in rural development, housing subsidies, food stamps and more to combat poverty. And they tried to do it differently, creating a locally-governed model where the President’s Office of Economic Opportunity required “maximum feasible participation” of citizens in order for the money to move.  Innovations like this made a difference.  For example, Native communities served by Indian Health Services were given better tools to manage their own health systems.
 
Medicare and Medicaid were formed against this backdrop. For most Americans, these programs are still the crux of the United States’ health care system today. Both programs were part of the War on Poverty. But Medicare and Medicaid were designed, named, and treated differently—despite serving the same function: health insurance. 

Medicare is federally-funded health insurance for older adults. Medicaid is state and federally-funded health insurance for the poor (that’s why ‘aid’ is in the name). Until the ACA was passed, Medicaid was mainly available to families with children, pregnant women, and people with disabilities.
Perception-wise, Medicare and Medicaid are divided in their depictions: by race, age, gender, haves and have-nots. In reality, many individuals who sign up for Medicaid are also elderly and eligible for Medicare.  Policy wonks call them ‘dual eligibles’. However, our country’s complicated relationship with its racial history, and a very particular narrative of ‘boot-straps individualism’ has led us down a troubling path.
 
Medicare and Medicaid were designed in a particular political moment.  They reflected the racial, class, gender, and regional divisions of that time.  Those divisions have set up the attacks on these programs that continue to this day. 
 
The unwillingness of Americans to look our past squarely in the eye leads to a very perplexing (and very American) set of blind spots.  Never mind that Medicaid serves more whites than people of any other race.  Or that roughly 1 in 5 Southerners are enrolled in Medicaid or the federal Children’s Health Insurance Program (CHIP).  Never mind that 15% of its enrollees are people with disabilities.  Never mind that it is run by states and is a source of state innovation.
 
Even Medicaid’s role in the Affordable Care Act was oddly invisible.  The two largest coverage expansions of the ACA were: creating state exchanges for individuals (like MNSure) and expanding Medicaid eligibility.  And Medicaid expansion was the bigger of the two.  In 2011, Mark Dayton’s first official act as governor was to sign an executive order bringing Medicaid expansion to Minnesota.
 
There is a reason why Members of Congress will propose cuts to Medicaid: it serves the poor, maybe even the ‘undeserving poor’ and children (who can’t vote).  And at the same time, too many elected officials avoid taking on the real reasons why health care costs are rising.
 
Our health care system was erroneously divided by policy decisions made half a century ago. National health care costs, driven by end of life care, are unsustainable.  And when age and poverty intersect (like with ‘dual eligibles’) the costs of care grow.  Steeply.  And disproportionately.  Having made less in their working lives and living longer overall, women make up over 60% of dual eligibles. This leaves our system is in peril, divided, and without enough common space to find solutions together. 
 
We should be at a point in our history where we take on these taboos in politics, and others, and identify how they relate to each other.  Yes, this means conversations about race, class, and gender, and difficult conversations on matters like end of life care and the costs of those last months before death. Instead we’re relitigating decisions made 50 years ago and scoring political points attacking programs for the simple reason they carry the name of the opposing party’s president.  Never mind that many of the tenants of that law were originally Republican ideas. 

The era that saw Medicaid and Medicare created to fight the war on poverty was an era that would be recognizable today, marked by denigration, resistance, and transformation. Thanks to the technology of satellite television, families across the country had watched dogs turned loose on peaceful civil rights activists, images that would be hauntingly mirrored in 2016 when dogs were used against water protectors trying to block construction of the Dakota Access Pipeline.

But we must also understand the differences between health care fights of the past and today’s in order to know the way forward. Future generations of public leaders must broach this conversation; it can’t be a taboo topic forever.

Thanks for diving deep into this conversation with me. Now, I want to hear from you. What do you think? We published this email on our website, it’s here. Would you share it with others? Why? Send us an email at info@takeactionminnesota.org. 

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