In its landmark 50th anniversary, the Social Security Act legislation that contains Medicare and Medicaid has undoubtedly been a force to be reckoned with throughout the course of health care’s history. This legislation–the 97th bill introduced in Congress that year, passed in six months, and signed by President Johnson–has been an issue of debate and a source of much contention over its fifty years, but panelists sitting on both the Medicare and Medicaid 50th Anniversary special sessions noted how the programs’ longevity is astounding.
50th Anniversary of Medicaid
During this panel, some of Medicaid’s leading policy thinkers and researchers discussed the program’s evolution since the law’s passage in 1965: its history, what we know from research, where there are opportunities and challenges moving forward, and the political dynamics involved. Sara Rosenbaum kicked off the session with a reminder:
“While Medicaid has been a vital source of health insurance, growing more so every year, and has been the basis of tremendous health services research into the health care needs of poor and disadvantaged populations and how well financing meets those needs, Medicaid is also a law. And Medicaid as a law has had a remarkable life in the law, which is something that is overlooked in the program’s history.”
Much of the story of Medicaid policy over the past half century is the story of the courts—an aspect “absolutely central to understanding it.” Through the courts and congressional action, Medicaid has experienced many evolutions, and yet, despite those changes, its basic structure and foundation remains intact; it’s a partnership between the federal government and the states that has endured for 50 years and is a fascinating case study for those interested in health policy history.
Reaching an apex in NFIB v. Sebelius, Medicaid has been the battleground on which the fraught question of federalism has played itself out. Over time, the program has evolved to meet changing population needs. Among its adaptations have been meeting children’s needs beyond health insurance through the Early Periodic Screening, Diagnosis, and Treatment (EPSDT) Program; adding the disabled, elderly, and blind populations to the program; and severing ties between it and welfare.
From a state lens, Medicaid’s history and its opportunities and concerns have transcended politics. As Trish Riley, National Academy for State Health Policy, said, “It would be a mistake to base too many conclusions based on the party in control” because the cost and growth of the program is a concern for all, and that concern increases all the time. Interestingly, she noted, while states are concerned about cost, 60 percent of those incurred costs have been optional; states chose it.
Yet, as all panelists noted in some capacity, Medicaid is wrought with difficulties. With the growth in the program and the variation in populations served, there is enormous complexity. Furthermore, as Benjamin Sommers, Harvard School of Public Health, described, managing and improving upon Medicaid becomes increasingly challenging. Some people don’t realize they have Medicaid, what it entails, or when their coverage has lapsed–factors that will only become more complicated under the Affordable Care Act. There is also the added complexity of multiple types of care delivery, in other words, ’50 states, 50 Medicaid programs.’ As a result, Medicaid is difficult for researchers to study.
The areas where researchers have studied, Genevieve Kennedy said, reveal that no matter where Medicaid is expanded, no matter the implementing state and its enthusiasm or lack thereof, public health insurance responded and there was lower uninsurance among the target population. Beyond coverage, researchers are consistently finding an increased likelihood of having a usual source of care and receiving a broad range of preventive and other health services. There is also evidence that Medicaid improves self-reported mental and physical health and depression screening.
Moving forward, there is much space for health services researchers, who can help answer questions about things such as program trade-off, i.e., “Medicaid compared to what?” In a world contemplating different ways to provide coverage, it is difficult to know what to make of the literature on quality and the other alternatives available. Medicaid continues to grow despite being under attack, and those accounting for the difference between rhetoric and reality, are health services researchers.
50th Anniversary of Medicare
“The objective of this session is not to celebrate the triumphs of the past,” said Robert Reischauer setting the stage for the panel, “…but rather the purpose of this session is to reflect on and discuss the roles that HSR has had on the evolution of Medicare.”
Don Berwick did this by citing evidence on variation in practice as the most important aspect of health services research to inform Medicare policy. Using data from geographic variations to craft legislation that works for diverse states continues to be vitally important. He also outlined a “wish list” of topics for health services researchers to focus on over the next three decades:
- Research on how to train physicians to change the delivery system;
- Transition models and financial plans;
- Data on scale and change in delivery systems;
- How to change the demand of consumers;
- The study of waste and its forms;
- New roles, workforce distribution; and
- Telemedicine and telehealth.
Karen Davis spoke to the history of the program: how health services research shaped Medicare and how Medicare has impacted health services research. “Medicare has shaped the health services research community by developing the databases for claims data…it provided a wealth of information that let us understand what was going on with the health system as a whole,” she said. She also cited the desegregation of hospitals as a way in which Medicare impacted health services research. Due to Medicare’s provision to receive hospital funding, hospitals had to be in compliance with the Civil Rights Act. Health services research documented the increased use of hospital services of elderly African Americans. She concluded that research has helped shape and make Medicare an innovator in coverage design and payment/delivery system.
Jon Christianson discussed the impact of health services research on private markets and competition on Medicare and focused on managed care programs. The opportunity for future research in these sectors, he outlined, include payment options and how risk is handled and noted the importance of private sector research on influencing Medicare. He ended by speaking to the current challenge of consolidation on the provider side and called for health services researchers to help address it.
David Durenberger concluded by addressing the ongoing need for health services research to inform policy and help lawmakers make decisions on health care reform legislation. Highlighting Medicare’s impact on HSR, he cited Medicare as a rich source of comparative data for health services researchers. He stressed the importance for health services researchers to stay the course and continue to keep lawmakers focused on the goal of health care reform by using evidence and data.
Each of these panels at the 2015 Annual Research Meeting succeeded in providing a panoramic view of the two programs, considering the past and future of Medicaid and Medicare and thinking long-term about their futures in an era of health reform.