Democrats and the Struggle over Medicare

Making Molehills out of the Mountains

As the initial implementation of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (PDIMA) proceeds in a welter of confusion, misinformation, and charges of manipulation and deceit, it appears unlikely that the Bush administration will reap the political benefits it sought when it appropriated a Democratic issue and displayed its “compassionate” conservatism. A remarkably cynical and complex piece of legislation even by the standards of contemporary Washington, PDIMA may well implode under its own weight. Even if it is ultimately judged a partial success, everyone knows that Medicare will have to be revisited in the next Congress or the one after that. But PDIMA’s failures hardly make for a Democratic victory. On the single issue on which Democrats should have the greatest political and rhetorical advantage, they have ceded the agenda to the Republican right and have let themselves be trapped in a posture of naysaying and defensiveness. Generalizing about “Democrats” is a particularly risky exercise. I personally have had the privilege of working with perhaps a dozen member of the U.S. Senate and perhaps two dozen members of the House of Representatives-and many veterans of the executive branch-who feel about these issues much as I do, and have probably done much more to promote effectively our shared ideas. But they are far from being the dominant group of party leaders.

Democrats have reasons to be proud of Medicare. A priority of three Democratic presidents, it was enacted by a Democratic Congress over protracted and strenuous Republican opposition (historically concealed by the fact that, once the battle was effectively over, most Republicans voted for passage of what had become, after fifteen years, a fait accompli). It has been remarkably successful. Health status and longevity among America’s elderly have improved dramatically as a result of Medicare. In general, the United States does poorly on comparative international measures of health systems performance: our life expectancy is lower and levels of untreated illness are higher, except among persons sixty-five and older, where the United States outperforms the rest of the world. Black and Hispanic Medicare beneficiaries do less well than their white counterparts, but the difference is significantly smaller than in other age groups. Medicare has also served as a major factor in the development and expansion of what is best in the American health care system, in the facilities and technologies of its teaching hospitals, outpatient centers, and rural clinics. Its administrative costs are the lowest of any major health insurance program in the world.

And Medicare is enormously popular, not only with its beneficiaries, who are probably more satisfied with the program than it really deserves, but also among the non-elderly, who know much less about the program, but remain highly supportive. The much-vaunted i...