Charles Blahous Channels Wilbur Mills: Warns states to not expand MediCaid!

Charles Blahous, Medicaid Trustee warns state to NOT expand MedicAid

Charles Blahous, Medicaid Trustee warns state to NOT expand Medicaid (image by Charles Blahous)

In an excellent article, Charles Blahous, one of Medicare’s Trustees, warns states of the dangers of the expansion of Medicaid.  He makes many of the same arguments that I have been making for quite a while, his warning, as a Medicare Trustee, may finally cut through the background noise and get some people to actually pay attention.  You can read the full Report by Mr. Blahous here: http://mercatus.org/sites/default/files/Blahous_MedicaidExpansion_v1.pdf

Mr. Blahous reminds me of Wilbur Mills who Continue reading

The Truth About Medicare/Medicaid and Social Security: Ok What Do We Do Now?

President Roosevelt signs the Social Security Act of 1935

“We can never insure one hundred percent of the population against one hundred percent of the hazards and vicissitudes of life, but we have tried to frame a law which gives some measure of protection to the average citizen and his family against the loss of a job and against poverty-ridden old age.”

President Franklin Delano Roosevelt said as he signed the Social Security Act into law August 14, 1935.

“Care for the sick. Serenity for the fearful”

were the words Lyndon Johnson expressed some thirty years later Continue reading

Medicare-Medicaid: A Chicken in Every Pot

“. . . I think we’ve got you something that we won’t only run on in ’66, but we’ll run on from hereafter!” - Wilbur Mills to President Johnson on Medicare in 1965.

As Congressman Wilbur Mills commented to President Lyndon Johnson, in a taped private conversation in 1965, he was encapsulating the primary benefit that the democrats of the day felt they would gain from the Medicaid and Medicare extension to the Social Security Act of 1935, and the primary reason that President Johnson and his team pushed so hard for the reform to include new entitlement programs for the elderly, the disaffected, and disillusioned.

The Historical Perspective

Wilbur Daigh Mills, democratic member of the U.S. House of Representatives, and the chairman of the powerful Ways and Means Committee, was considered, by many, to be the only person in Congress who truly understood the actuarial basis of Social Security, and was recognized as the Congress’s primary tax expert.  At the start of the war on poverty in 1964, Mills had serious concerns as to the affordability of the existing Social Security Act of 1935 for the nation, let alone any extension of the current benefits to include what was then viewed as a health care “safety-net” for the underserved and the elderly.

Mills did not believe that the nation’s tax system could fund the liability of Medicare.  In his paper, “The Origins of Medicare,” published in 1999, Robert B. Helms writes,

Even in the face of strong political pressure from other Democrats, Mills had been so consistent in his opposition to adding a medical benefit to Social Security that many suspected him of being sympathetic to the AMA’s socialized medicine arguments. He used his detailed knowledge of Social Security to question both the Kennedy and Johnson administrations’ cost estimates and to point out that estimating future medical costs was a much more difficult task than estimating the future costs of a cash benefit.

In a 1964 speech, Mills said: “In practical terms, this meant that if the hospital insurance system which would be created by the bill was to remain sound, the taxable wage base would have to be increased by $150 each year. Clearly, this would be a case of the tail wagging the dog.” (The taxable wage base increased an average of $46 per year from 1959 to 1964)

In that same speech, he pointed out that hospital costs were increasing at a rate of 6.7 percent, while average earnings were increasing at only 4 percent (1955 – 1963), and that he saw no reason to assume that the situation would change. His support for the final version of Medicare in 1965 was apparently due to the effects of Democratic gains in the House in the elections of 1964, President Johnson’s personal appeals for support, and the many technical changes that he was personally able to insert into the bill during its various stages of development.

We now know that Chairman Mills’ skepticism was justified: In 1964, the administration projected that Medicare, in 1990, would cost about $12 billion in 26 years (which included an allowance for inflation); the actual cost was $110 billion. We may not know until the year 2025 if today’s actuaries are any more accurate than those in 1964 in making twenty-six-year projections, but at least the current crew is leaving no stone unturned to tell everyone who will listen that the Medicare Part A trust fund does not meet their standards for short-term or long-term actuarial soundness.

Despite Mills’ dire warnings, and his correct calculation that the wage base would have to increase by 300% each year over the existing rate to afford this new entitlement, Johnson felt he was swept in with a clear mandate from the people due to his landslide victory in the 1964 election. So, to help drive increases in the Democratic Party majority in congress, he made the push for Medicare one of his primary platform goals. Johnson was so focused on getting Medicare pushed through congress, he was willing to leverage anyone, and everyone, with every tool he had at his disposal to get this divisive legislation approved. The following transcript, of a taped meeting with his Vice President, Hubert Humphrey, in the first days after the election, is quite telling.

Johnson: “They are bogged down. The House had nothing this week-all god-damn week. You and Moyers and Larry O’Brien have got to get something for them. And the Senate had nothing . . .  So we just wasted three weeks . . .  Now we are here in the first week in March, and we have just got to get these things passed . . .  The ones that I’m really interested in . . .  one of them is education, one of them is Medicare, and one of them is Appalachia . . .  I think the medical care will go through like a dose of salt through a widow-woman . . .  You’ve got to look each week and say, what is the Senate doing in Committee this week and when will they be through, what is the House doing . . .  You’ve got to be running into these guys in the halls, and going over and having a drink with them in the evenings . . .  I want that program carried. I’ll put every Cabinet officer behind you, I’ll put every banker behind you, I’ll put every organization that I can deliver behind you . . .  I’ll put the labor unions behind you.

Johnson’s election didn’t just change the Democratic Congress’s advantage over Republicans; it also changed Mills’ political view. Seeing the writing on the wall, Mills made another speech where he announced, “I can support a payroll tax for financing health benefits just as I have supported a payroll tax for cash benefits (meaning social security).”
Thus, began what has been termed by many as the greatest Ponzi scheme to ever be foisted on the American people. With Mills’ support, the measure passed. There were still several hurdles to overcome, but in the end, Johnson got the legislation he wanted, regardless of the consequences. On March 23, 1965, Johnson’s Oval Office taping system records the call he has been waiting for from Wilbur Cohen (architect of much of Social Security and Medicare), Wilbur Mills (Chairman of the Ways and Means Committee), Carl Albert (Democratic Majority Leader) and John McCormack (Speaker of the House) telling him the bill has just passed out of the Ways and Means Committee. It is the first time Johnson finds out what Cohen has just actually agreed to in Johnson’s name: (Listen to the Johnson Tapes on-Line)

Mills: We wound up, and I got instructions, we’ll introduce the bill at noon tomorrow, and will report it at 12:15 . . .  I think, we’ve got you something that we won’t only run on in ‘66 but we’ll run on from here after.
Johnson: Wonderful. Thank you, Wilbur.
Mills: Now here is Wilbur Cohen.
Johnson: When you going to take it up?
Mills: We could have it on late next week, if not, early the following week.
Johnson: For God sakes, let’s get it before Easter.
Mills: Oh, there’s no doubt about that.
Johnson: . . . I sure do congratulate you on getting this one out . . .  I congratulate you and thank you.
Cohen: I think it’s a great bill Mr. President.
Johnson: Is that right?
Cohen: Yes sir. I think you got not only everything that you wanted, but we got a lot more . . .  It’s a real comprehensive bill.
Johnson: How much does it cost our budget over what we estimated?
Cohen: Well, it would be, I would say, around $450 million more than what you estimated for the net cost of this supplementary program.
Johnson: What do they do under that? How is that handled? Explain that to me again, over and above the King-Anderson, this supplementary that you stole from Byrnes.
Cohen: Well, generally speaking, it’s physician’s services.
Johnson: Physicians. All right, now my doctor that I go out and he pumps my stomach out to see if I’ve got any ulcers, is that physicians?
Cohen: That’s right.
Johnson: Any medical services that are M.D. services?
Cohen: Any M.D. services.
Johnson: Does he charge what he wants to?
Cohen: No, he can’t quite charge what he wants to because this has been put in a separate fund and what the Secretary of HEW would have to do is make some kind of agreement with somebody like Blue Shield, let’s say, and it would be their responsibility . . .  that they would regulate the fees paid to the doctor. What he tried to do was make sure the government wasn’t regulating the fees directly . . .  the bill provides that the doctor can only charge the reasonable charges, but this intermediary, the Blue Shield, would have to do all the policing so that the government wouldn’t have its long hand . . .
Johnson: That’s good. Now what does it do for you the patient, on doctors. It says you can have doctor’s bills paid up to what extent or how much? Is there any limit?
Cohen: The individual patient has to pay the first $50 deductible, then he’s got to pay 20 percent . . .  of everything after that . . .
Johnson: That keeps your hypochondriacs out?
Cohen: That will keep the hypochondriacs out. At the same time, for most of the people it will provide the overwhelming portion of their physician’s costs.
Johnson: Yes sir, and that’s something nearly everyone could endure. They could borrow that much, or their folks could get them that much to pay their part . . .  I think that’s wonderful. Now remember this, nine out of ten things I get in trouble on is because they lay around. Tell the Speaker, and Wilbur, to please, get a rule just the moment they can . . .  That damn near killed my education bill, letting it lay around. It stinks. It’s just like a dead cat on the door. When a Committee reports it, you better either bury that cat or get it some life.

In the end, Medicare and Medicaid became the law of the land. And, as can now know, Mills was correct to have his doubts about the actuarial basis of Medicare, Medicaid, and Social Security when the bill was passed in 1965. But, like the Social Security Act of 1935, the 1965 Act was not an ending, but a beginning of a perpetual series of expansions of the benefits provided by these programs.

It is now painfully clear that Wilbur Mills was correct in his initial assumptions about both the solvency of the original Social Security Act of 1935 and its unprecedented expansion in the 1965 amendment that pushed through for significantly political reasons by President Johnson.  Mills estimates of what would be required in real taxable earnings gains in order to fund this “safety net” were eerily prescient. By 1974, the failure of the GDP to support the nation’s expenses for these entitlements, and the accumulating trade deficit, had placed the country in a significant cash shortage with few means of escape.

President Richard Nixon took us off the gold-standard, and by the late 1980s the significant, arbitrary increases in the currency had elevated almost everyone’s wage base to where they began to feel prosperous once again.  But, the costs were just being temporarily outpaced by the injection of this new currency, the day of reckoning was still coming and finally hit with a vengeance in 2009. It is now starting to become clear that the feeling of prosperity we all experienced was not the reality of our economy just the benefit of more baseless cash.

The Modern Perspective

Enter a few days ago our current President, Barack Obama. In the past few days, it is clear to me that the president still believes what Wilbur Mills told President Johnson in 1965.  He clearly believes that he should be able to run on the entitlements of Medicare and Medicaid to secure the votes for this free stuff, just like President Johnson.  The concept of “a chicken in every pot,” i.e. votes for free stuff, was not as much the hallmark of the Democratic Party prior to President Johnson.

Although President Franklin D. Roosevelt leveraged these ideals to help the country rise out of the Great Depression and prepare for WWII, and Herbert Hoover is often credited with the phrase; “A Chicken in Every Pot” is a quotation that is perhaps one of the most mis-attributed in American political history. Variously assigned to each of four presidents serving in the years between 1920 and 1936, it is most often associated with Herbert Hoover. In fact, the phrase has its origins in seventeenth century France; Henry IV reputedly wished that each of his peasants would enjoy “a chicken in his pot every Sunday.” Although Hoover never uttered the phrase, the Republican Party did use it in a 1928 campaign advertisement touting a period of “Republican prosperity” that had provided a “chicken in every pot—and a car in every backyard, to boot.” You see, we need to understand that political duplicity is not a democratic or republican affectation; it is a politician’s con.

But here we are once again, and even though President Obama is not uttering this phrase, it is clear that this is what he sees as his ticket to re-election.  Perhaps I am too cynical, but reading transcripts of committee hearings on what became the Affordable Care Act, listening to our congressional leadership saying things about the legislation like, “this is the path to a federal single payer system,” or “we need to pass it so we can see what’s in it,” and other equally ludicrous statements, and listening to the political agendas so blatantly expressed in the Johnson, or Nixon, tapes can do that to a person!

Based on my own experience, and backed up by the historical record all the way back to Mr. Mills, it is clear that the current system simply cannot work.  Frankly, and I don’t think I am telling anything out of school, none of our elected officials think it can work either.  They are currently almost evenly split between the “we know it can’t work and we need to fix it crowd,” and the “We know it can’t work but we can run on it again, and again, and again… crowd.” Regardless, to everyone it should now be clear that it can’t work.

So, it is astounding to me that the President of the United States, Barack Obama, now stands before the American people and making a reverse Robin Hood argument declares that the other party, Republicans, in this case, those evil people, want to take everything you have away and give it to the rich!  And what is more astounding is he says this is not class warfare!  People seriously can’t believe that such a bald faced lie can be true, can they? I have met many of our congressional leaders; republican and democrat.  I have not met one that was not concerned about all Americans.

To make a statement that one political party is dedicated to the destruction of poor and helpless people is beyond unconscionable it is simply irresponsible.  And it would be equally irresponsible for similar invectives to come from the other side as well.  We are in a significant national, social and economic crisis.  If our leaders do not get serious about solving the problems then we need to get new leadership.  If all we have left when someone talks of hard choices is to damn them as a pawn for the rich, then I do not see how we will survive.

As we move beyond this primary election cycle toward the presidential election, we need to elect a leader that will realize that he can’t promise America that there will not be a chicken in every pot.  You see Mr. Obama; the chickens have finally come home to roost!

(for those of you who may be interested in more on this issue, it is discussed in more detail in my upcoming book, “The History and Evolution of Healthcare in America,” go to my website at www.loker.com and sign up to receive notice of its release.)

Entitlement vs. Safety Net: It’s not a matter of degree!

Well, let me start with this disclaimer! I am not anti-social security, anti-Medicare or anti-Medicaid…  I am saying this in advance of the e-mails I know I will get from the people who will not read the article clearly and will stop thinking just as soon as they believe one of their special programs might be threatened.  I believe very strongly that we need a safety net—it’s just the current system we have is no longer a safety net.

The headline in my local paper says Brown seeking Medi-Cal cuts: Governor requests flexibility from the White House.  For those not in California, Brown is our Governor Jerry Brown and Medi-Cal is California’s implementation of Medicaid.

I am going to keep this short and sweet, if I can.  We should comment Governor Brown for taking the initiative to address the overwhelming costs of Medi-Cal (Medicaid) that is bankrupting our state.  California is in a much worse position than most of the other states because, as the Governor found out when he took office, California is in the top one or two of any state in any measure of the amount of entitlements we are providing to our population per capita. In his first budget, Gov. Brown took on this issue and began the effort of reducing these most generous programs, which may have made sense when we were one of the richest economies in the nation, to the median benefits offer of all the national state programs.  I think this is a very pragmatic, and still generous, approach considering we are now the top state in the national measure when you look at fiscal insolvency.

We need to address this issue now as the time has run out as our deficit build and we become one of the most cost ineffective places for business in a national economy that is one of the most cost ineffective locations to do business on the planet.  Kudos to Governor Brown for taking these very hard steps directly in the hard face of his own parties’ public ideology and attempting to get to a solution to this massive problem.

But overall the problem is not one of just Medi-Cal in California. It is a much larger problem, a systemic one. It is a problem that traverses all the programs including Medicare and Social Security. Beginning with the Social Security, conceived as a temporary safety net program to help the aged who had their savings and investments devastated by the one-two punch of the collapse of the stock market followed quickly by the depression as a result of the great drought induced dust bowl in the mid-west. In turn, Social Security and the myriad programs that have followed have evolved from that of a simple safety net. Originally, first seniors, and then others, could look to these safety nets as a small aid to what they could earn and save for themselves to tide them through a short difficult time that may occur beyond their real ability to plan. Now with the extension of Social Security to include Medicare and Medicaid, these programs are not viewed as a safety measure but as a replacement.

If we look to Medicare as an example, it can be argued that it is a vital insurance program to support the healthcare needs of our aging population and our disabled. And for some this is clearly the case. But it can also be argued that for many, even though the checks are being written to providers covering their health care needs in later years, if this is really supposed to be a safety net, the government is not paying for their health care; it is paying for the purchase of that flat panel TV when I was forty-five, or the vacations I took, or the new car I purchased every four years, or some other expense I would not have made if I had not had the expectation of the government picking up the tab for my potential catastrophic healthcare needs in my last five years of life.

I know the former discussion is not a pleasant one to have as it brings us back to the point that our actions today have ramifications for tomorrow. In the generation prior to mine, they had the belief that they needed to save much of their excess money for a rainy day. We have come to believe that the rain is now offset by our wonderful and blatantly generous Uncle Sam. So, we are empowered by the change from the safety net to that of an entitlement, to believe we are OK to purchase that vacation home, instead of saving the money because when, not if, we get sick, Medicare will take care of it. I remember my father preaching to me siblings and I in the 1960s that we should never count on these programs because a.) It was our responsibility to plan and pay for ourselves and family—not our neighbors responsibility, and b.) The government will probably not have the money when we need it as this system just won’t work.

Well thanks for the advice Dad, I took it to heart and have followed your example. But, despite my savings we, the citizens of the U.S. and of California are at the point you so correctly predicted and poor California’s Governor Jerry Brown now has to be the first state leader to start to take away all the things we have been trained to be dependent on. You see much of these expenses are no longer about emergencies and simply providing for a base existence, they are now becoming more about quality of life. It is not enough to provide basic services for the poor; we need to also give them cell phones.

I don’t want to see people suffer, and I don’t want to deprive people of some form of basic existence. But with the coffers bleeding cash at a pace that is now in excess of what we can produce on an annual basis we need to start to make distinctions between, emergency necessary for life services and those services that provide more for the quality of life! I commend Governor Brown, for taking these steps. I know they are not easy for him because of his strong humanitarian heart. I am glad he was not just imbued by our creator with that humanitarian heart but also received the gift of a great mind that recognizes we need to find pragmatic adjustment and exceptional courage to take the unpopular steps to find a solution. With this accolade also comes caution. We need to remember that even Governor Brown is human, and is in a system that will require him to make some decisions that he and the rest of us will not like, simply to get part of this done. We can expect all the purists to take shots at every single deficiency and change from all sides with no recognition as to the realty of a public and political governmental process.

Regardless, I will say I appreciate what he is trying to do, and will attempt, even when he make decisions, like High Speed Rail, that I fundamentally disagree with, that he is doing this based on his befief that it will contribute overall to the solution of this complicated equation for the viability of California and its citizens.