1965

Passage of Medicare predicated on exceptionalism re the elderly middle-class: “The elderly were carved out as an exception – but an exception that would allow the traditional mechanisms to continue to enjoy their dominance (Rothman II, 69). . . . The defense of Medicare, and the design of Medicare, made it the more likely that its passage would mark the end, not the beginning, of national health insurance (72). . . . So intent were the champions of Medicare in demonstrating the exceptionalism of the elderly that they ignored the deficiencies of private insurance for the young. Rather than issue a broadside attack against a system of health care delivery that depended upon voluntary insurance, rather than calculate whether part-time employees could afford the rates or the deductibles, rather than analyze whether other Americans had difficulty coping with policy exclusions, Medicare’s advocates made it appear as if the elderly were the only victims of these stipulations” (77). Medicare’s pragmatic rebuttal to the proposition that health care was a right was to adopt “the position that Medicare benefits would be paid for by the recipients during their working years, and to this end, they made Medicare part of the Social Security system, not a program standing alone” (83-84). Home care (“home health care”) was a provision of Medicare; it was “a political strategy, more symbolic than emblematic of true budgetary considerations. The perceived capacity of home care to empty hospital beds destined it to become a post-hospital benefit in the Medicare program. Following a hospitalization of at least three days, patients could receive up to one hundred home care visits” (Buhler-Wilkerson, 199). . . . Medicare redefined home care to include only those selected functions and prescribed circumstances that were reimbursable. This time, a federally sponsored insurance system sought to establish home care as an alternative to institutional care. Once again, the payment system created a narrowly defined, fragmented, and uncoordinated set of acute-care services ill adapted to the needs of the chronically ill at home” (201). . . . “The maze of entitlements, functional eligibility requirements, and continuous shifts in reimbursement sources proved self-defeating for a policy created to encourage community rather than institutional care” (202).