When Medicare was launched in 1965, it wasn't at all clear that it would be as popular and valued as it is today.
Marilyn Moon, an Augusta native who now is a fellow at the American Institutes for Research and director of the Center on Aging in Maryland, said early opponents of Medicare warned it would be the end of health care as we knew it. Some doctors threatened to boycott Medicare and refuse to see patients who relied on it.
Hospitals, especially in the South, also threatened a boycott because Medicare required they be racially integrated. The National Guard was put on notice to be prepared to integrate hospitals, much as it had Southern schools.
At the time, future President George H.W. Bush famously called it "socialized medicine," and Ronald Reagan ominously suggested if Medicare wasn't stopped "you and I are going to spend our sunset years telling our children and our children's children what it was once like in America, when men were free."
But by 2011, a Harris Interactive poll found that Medicare and crime fighting were the most popular federal programs, supported "a great deal" or "somewhat" by 88 percent of those polled, slightly ahead of Social Security.
"The irony of it is that it kind of happened with a whimper rather than a bang," Moon said. "It started and people suddenly began getting care and doctors found they were going to get paid for caring for people who in the past they often had to do with charity care."
Today, there's a similar furor leading up to full implementation of the Affordable Care Act on Oct. 1. "I think there are some things that are very analogous and I think they reflect the fact that none of us likes change, and when it's something as important and complex as health insurance, that's scary to people," Moon said.
But Moon thinks that 10 or 15 years down the road, Obamacare will be just as accepted, just as integrated into American life as Medicare is today.
"I think one of the important lessons is that a lot of people talk about things that are going to happen that are scary, and they turn out not to be the case," said Moon, who spoke at the Sept. 24 Sunflower Fair, an event sponsored by the North Central-Flint Hills Area Agency on Aging.
Today, she said, Medicare is one of the two most popular federal programs. Its beneficiaries consistently give it higher ratings that the beneficiaries of private insurance, said Moon, who has a Ph.D. in economics from the University of Wisconsin and has been a public trustee for the Medicare and Social Security trust funds.
Medicare, Moon said, actually was a more revolutionary idea in 1965 than the health care overhaul is today.
"It was a major break from how people got insurance in the past because it was coming from the government when in the past only private insurance was possible," Moon said. "That's even more of a change than the Affordable Care Act. The irony of the Affordable Care Act is that the people who designed it designed it to try to be as undisruptive as possible. Part of the reason it's so complicated and clunky in ways is that the notion was to try to work around all the folks who currently have insurance and keep private insurers operating."
Under the ACA, most familiar private insurance companies, and some new ones, will offer their plans through the health care exchanges to consumers who don't have employer sponsored insurance.
"What's really different in terms of the Affordable Care Act for people is that there's an exchange out there where you can get all the information in one place, not just from the person who is trying to sell it to you directly, i.e. the insurance company. There are requirements that they all have to play by similar rules."
In 10 to 15 years, she said, some states may regret not taking the opportunity to set up their own insurance exchanges and expand Medicaid eligibility under the Affordable Care Act.
"The federal government is going to fully pay for that," she said of Medicaid expansion. "What is so terrible about making sure that very low income people get access to insurance? I know hospitals are wildly in favor of that because they won't have to deal with so many uninsured (people)."
Colorado, for example, set up its own health care exchange and last month announced that 13 insurance companies would offer 150 individual plans and 92 for small businesses through the exchanges. Colorado also approved an additional 299 plans that can be purchased on the open market.
Colorado launched a $2 million public awareness campaign in May, including television, radio, print and billboard advertising in English and Spanish and outreach through social media. Kansas has had no public awareness campaign other than employees of the Kansas Insurance Department visiting cities for public question and answer sessions.
Like Florida, Kansas also did not expand Medicaid eligibility. Kansans generally are eligible for Medicaid only if they are extremely poor, making no more than 32 percent of the federal poverty level, or $7,500 for a family of four. The ACA raised eligibility to 133 percent of poverty level, or $31,322 for a family of four, but the U.S. Supreme Court said states could not be compelled to expand Medicaid eligibility, and the Kansas Legislature opted not to.
That will leave a substantial number of Kansans without insurance and without help to get it. The maximum income for Medicaid eligibility in Kansas is still far below the income level at which federal subsidies help offset insurance purchased through the exchanges: $11,490 for individuals and $23,550 for a family of four. That's because the Affordable Care Act, as written, didn't provide subsidies below those incomes because those families would get Medicaid instead.
Additionally, under Kansas regulations, single able-bodied adults are not eligible for Medicaid at any income level. Kansas Insurance Commission Sandy Praeger recently estimated that 130,000 to 150,000 Kansas adults would "fall between the cracks," too rich to qualify for Medicaid, too poor to qualify for subsidies for insurance.
Many elderly people have taken a keen interest in Obamacare because they worried about how it will affect their Medicare, the federal insurance for people over 65.
That answer, Moon said, is not much. They don't have to do anything different. They are, however, getting some improved benefits since the Affordable Care Act became law in 2010.
ACA stipulates that many preventive care services are now fully paid for by Medicare. It also is shrinking the "donut hole" in prescription drug coverage a bit each year through 2020. For instance, Medicare enrollees now have prescriptions covered up to a certain level, then have to pay 79 percent of the cost of generic drugs, 47.5 percent of brand name drugs, until they reach their annual maximum and Medicare begins paying for all the cost again.
Over the next seven years, the amount they will have to pay for generic drugs will be reduced 7 percent a year until it reaches 25 percent in 2020. The amount paid for brand name drugs will drop 2.5 percent in 2015, then 5 percent a year until it also reaches 25 percent in 2020.
The Affordable Care Act may be "a very good deal" for retired couples where one partner is old enough to enroll in Medicare but the other is still too young and doesn't have access to employer sponsored insurance.
Heretofore, pre-existing conditions were used by insurance companies to deny coverage to those seeking individual policies or to price coverage beyond the ability of people to pay, and Cindy Hermes, the director of public outreach at the Kansas Insurance Department. She noted in a recent public forum in Hutchinson that "by age 50, you usually have about three pre-existing conditions that would knock you out."
If one person has Medicare and a younger spouse doesn't, the one without insurance will be able to go on the exchange, shop for coverage and be assured that the insurance coverage is good and affordable.
Copyright 2013 The Associated Press