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Chapter 5: Who Makes Social Welfare Policy?

IN THE 8 years between the introduction of the original Forand bill in 1957 and final passage of Medicare, some 80 revisions, compromises, and alternatives had been drafted. Congressional committees conducted no fewer than eight sets of public hearings on the issue, and the published testimony from those exercises fills an entire bookshelf. The Ways and Means Committee gave more of its time to Medicare during this period than to any other subject. Likewise, the Congressional Record is laced with innumerable speeches and "insertions" on Medicare. The pre-vote floor debates alone would fill more than a volume.

Between 1957 and 1965, at least a dozen books and literally hundreds of television, radio, magazine, and newspaper features were devoted to various aspects of the issue. The opposing sides together probably made several thousand stump speeches and distributed millions of pamphlets. Though neither side admits to having added up its costs, total lobbying expenditures exceeded several million dollars.

Quite probably, the cost of the debate to the Federal Government also amounted to several million dollars--for the salaries of the legislators, departmental officials, numerous staff assistants, technicians, secretaries, and others who devoted all or part of their time to this issue. Such a reckoning would also have to include research expenses, paper and printing costs, telephone calls, and a host of miscellaneous items. Democracy is expensive--but it is a time-tested way of resolving conflicts.

In American society, as in most others, a delicate balance always exists between conflict and consenus. Without a relatively high degree of agreement on fundamentals, no orderly social and political life is possible. On the other hand, our diverse interests and ways of pursuing happiness-- as individuals and as organizations--frequently come into conflict with one another. Some theorists argue that such conflicts are a manifestation of human nature. Others take the position that such conflicts are simply a product of our culture, or, in the view of the Marxists, our economic system. But whatever the cause, conflict (as well as consensus) has been a major theme of American history.

Conflict was an important and highly visible aspect of the Medicare debate. Yet the contending parties also displayed a high degree of consensus. Both sides agreed to "play by the rules of the game" and accepted the decisions of the legislative process as binding. This is often taken for granted in our society, but it is no small achievement. Beyond that, the heated debate obscured the fact that there was substantial agreement on certain fundamental points. Neither side argued that the aged had no right to decent medical care ; ever since the 1930's, medical care had been accepted as one of the basic necessities of life which, as a last resort, society itself must provide. And if the aged were unable to pay for their medical care, it was the responsibility of society somehow to finance it.

The argument, then, centered on two issues: (1) Whether or not the aged, or a substantial number of them, did in fact need help with their medical bills; and (2) if they did, what mechanism should be employed to cope with the problem. As the debate progressed, the first point came to be accepted as true, although there continued to be differences over the seriousness of the problem. At the end the unresolved conflict was over means. Three basic alternative approaches were considered--either separately or in combination: (1) some form of Government subsidies for private insurance carriers as in the Flemming and Javits proposals, the Bow bill, and, finally, the AMA's Eldercare; (2) direct Government, payments for medical services to low-income elderly through State welfare agencies as in the "vendor payments" and, later, Kerr-Mills programs ; and (3) health insurance financed and administered through social security.

Each of these alternatives, along with their various administrative and technical features, had important social, economic, and political implications that influenced the preferences of the opposing sides. And, in the end, the issue could only be resolved through the political process. It was finally resolved in favor of social security (Medicare) supplemented by an expanded Kerr-Mills program of direct payments for health services to the elderly and other poor (Medicaid).

Who, then, makes social welfare policy decisions?

After President Johnson had finished his brief prefatory speech that day in 1965 when he was in Independence, Mo., to sign Medicare into law, he took a seat at a large table, next to former President Truman. Beside him in several racks were nearly 100 of the old-fashioned nibbed pens, which he was about to use to transform the Mills bill into Public Law 89-97. As photographers and news cameramen recorded the scene, the President began to construct his signature, using each of the pens in turn to stroke a fraction of his name and then ceremoniously giving the pen as a memento to one of the assembled notables.

The President's gesture, a tradition at bill-signing ceremonies since Franklin Roosevelt's day, was more than an act of flattery to his guests. It symbolized the theme of the President's prefatory remarks. The final victory of Medicare, he had said, was not attributable to the efforts of any one man. It mas attributable to the joint efforts of many--to at least a score of Congressmen and Senators (some of whom had died before seeing the fruit of their work), to dozens of departmental officials and technicians, to congressional staff people, to the leaders and staffs of the many interest groups and organizations which supported the measure, to newspaper and magazine editors who had endorsed it, to philanthropists, courageous physicians, committed intellectuals, dedicated pamphleteers, and self-effacing political organizers. All of these people and more contributed their ideas, their money, their labor, and their influence to the cause.

But perhaps the most important contributors were the four Presidents of the United States who had made health insurance under social security one of their goals. As the only official who owes his mandate to the entire American electorate, a President uniquely embodies the will of the people. He, more than anyone else, is obligated to speak and act for the Nation as a whole.

Thus, while the answer to the question may not conform to any theoretical blueprint of democracy, it does conform to the spirit of democracy.

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