When campaigning for the Presidency in 1960, John F. Kennedy made health care for retired Social Security beneficiaries a major plank in his platform. In the Senate he had already introduced a companion measure to the Forand bill, which had been introduced initially in the House by Congressman Aime Forand of Rhode Island. In a campaign speech Kennedy described his bill this way: "the bill provides that those who are on Social Security, working and contributing to Social Security, shall make a contribution so that when they are 65 years of age or older if they are men, or 62 if they are women, or over age 50 if they are totally disabled, they can receive assistance from the fund in paying their hospitalization, paying the cost of their examinations and drugs, and also receive some assistance in paying their general medical bills." (6) This was essentially what would become Medicare, although it went beyond Medicare in several respects. (7) This bill would fail to pass the Senate in 1960 by a mere four votes.

After becoming President, Kennedy addressed Congress on the need for his Medical Care for the Aged legislation, as part of a State of the Union address. He told the assembled members of Congress: "We need to strengthen our nation by safeguarding its health. Our working men and women, instead of being forced to ask for help from public charity, once they are old and ill, should start contributing now to their own retirement health program through the Social Security system." (8) In a subsequent speech he said, "We're not asking for anybody to hand this out, we are asking for a chance for the people who will receive the benefit to earn their way-the same principle established under the Social Security system in the 30s." (9) Deciding that this was the major issue in the mid-term elections, Kennedy put together a massive political push on the issue. On May 20, 1962 he addressed a rally of 20,000 people in Madison Square Garden on this issue, a speech which was broadcast live over all three television networks, while a cadre of 45 Administration spokesmen were holding simultaneous rallies in major cities around the country.

Despite Kennedy's efforts, the new version of his Medical Care for the Aged bill failed of passage in the Senate again in 1962, this time by only two votes. In a national television broadcast after the vote the President complained, "I believe this is a most serious defeat for every American family, for the 17 Million Americans who are over 65, whose means of support, whose livelihood is certainly lessened over what it was in their working days, who are more inclined to be ill, who will more likely be in hospitals, who are less able to pay their bills." He then made the issue a central political issue in the mid-term elections, telling the nation, "I think the American people are going to make a decision in November as to whether they want this bill, and similar bills, to be passed, or whether they want it to be defeated. Nearly all the Republicans and a handful of Democrats joined with them to give us today's setback. . . .We have to decide, the United States, in 1962, in November, in the Congressional elections, whether we want to stand still or whether we want to support this kind of legislation for the benefit of the people. . . .This bill will be introduced in January 1963. I hope it will pass. With your support in November, this bill will pass in 1963." (10) The bill would be re-introduced, but the result would be the same.

Following Kennedy's death, Lyndon Johnson got a good deal of political mileage out of sentimental appeals to pass legislation as a tribute to the slain President. If he could plausibly claim that a bill was part of the dead President's legacy, it briefly had an extra boost it might not otherwise enjoy. Johnson certainly tried this tactic with Medicare. It failed repeatedly, but Johnson kept sounding the theme. In early 1965, as what would become the final successful bill was before the Congress, he told a group of government officials at the White House, in a tone which can only be described as maudlin, "The Social Security health insurance plan, which President Kennedy worked so hard to enact, is the American way. It is practical. It is sensible. It is fair. It is just." (11)

The Political Rocks-

The many efforts to enact something like Medicare, going back to President Truman's early ambitious proposals, foundered on a couple of familiar political rocks, and one surprising one.

The first obstacle was the opposition of the Republican Party to what were Democratic initiatives. During the debates on Truman's proposals stalwart Republicans like Robert Taft of Ohio counterposed plans which did not require the creation of government programs. Taft's plan, and similar alternatives during the Eisenhower years, were generally based on providing subsidies to private insurance companies to create incentives for them to cover the aged population. So the parties were divided over how to best approach the problem of medical care for the aged. Since the strength of either party was never overwhelming during this period, this divide was a serious obstacle to action. (The strength of the two parties was roughly equal, despite some ups and downs, until the landslide victory of Johnson over Barry Goldwater in 1964 Presidential election.)

The second, and most powerful obstacle, was the organized opposition of special interest groups, especially the American Medical Association (AMA). The AMA's campaign against the first Truman proposal actually marked the start of the AMA's role as a political lobby. Throughout all the various proposals, up to and including the final bill in 1965, the AMA was a major block to any change in the status quo. The AMA argued that any involvement by the government in the medical care profession was the equivalent of socialized medicine. This argument, especially during the height of the Cold War hysteria, had real force.

The AMA's campaign against Medicare also marked the beginning of the political career of another rising force in American politics-Ronald Reagan. Most conventional histories of Reagan's political career date his emergence as a political figure from his nominating speech on behalf of Barry Goldwater at the 1964 Republican Convention. But in 1963 Reagan was the AMA's spokesman for their campaign against Medicare. The AMA, in what was called Operation Coffee Cup, organized thousands of small meetings in homes all across the land, hosted by the wives of AMA physicians. At these informal "coffees" the women would organize local efforts against the pending Medicare legislation. This would include letter-writing campaigns to members of Congress, petition drives, networking with other civic groups, and the like. The central event of each meeting was the playing of a recording made of Reagan presenting a short, dramatic, speech against the evils of Medicare. Reagan played the socialized medicine theme to the hilt, suggesting that the idea of government sponsored medical insurance was little short of the entering wedge of socialist domination of America. His concluding appeal is typical of his sales pitch:

" . . . behind it will come other Federal programs that will invade every area of freedom as we have known it in this country. Until one day, as Norman Thomas said, we will awake to find that we have socialism. And if you don't do this and if I don't do it, one of these days you and I are going to spend our sunset years telling our children and our children's children what it once was like in America when men were free." (12)

Throughout his presidency, Lyndon Johnson surreptitiously recorded his telephone conversations. President Johnson intended that these recordings would not be open to researchers until 50 years after his death. However, in 1992 Congress passed legislation requiring release of most available information on President Kennedy's assassination. In response, the LBJ Presidential Library released President Johnson's phone conversations on this topic. Following the release of the Kennedy-related material in 1993 and 1994, the Library decided that the ban on release of the materials had effectively been broken, and the decision was made to gradually open the remaining materials to scholars and interested members of the public. To date, the Library has released President Johnson's Oval Office conversations through March 1966.

There have been many interesting revelations with the publication of Lyndon Johnson's secret White House tapes. Historian Michael Beschloss has published two books of excerpts from the tapes, and the C-SPAN broadcast network plays audio excerpts every week on its C-SPAN 3 radio service. (14) We can gain some modest new insights into how the passage of Medicare finally came about in 1965 from a review of the tapes. (15) The first issue of significance concerns personnel.

When Lyndon Johnson came into office he inherited President Kennedy's cabinet, including Secretary of Health, Education and Welfare Anthony J. Celebrezze. The number two official at HEW was the Undersecretary, Ivan Nestingen. The third-ranked player of importance was the Assistant Secretary for Legislation, Wilbur Cohen. In effect, these three officials were the ones responsible for the Administration's Social Security-related legislative agenda on Capitol Hill. In partnership with Lawrence O'Brien, who was Assistant to the President for Congressional Relations, these three HEW officials had the responsibility to push Medicare to a successful completion.

Celebrezze was a Democratic pol, a former big-city mayor (of Cleveland), who was a novice in Washington and not an especially impressive figure, although Johnson always treated his respectfully. Ivan Nestingen, before coming to Washington, had been the mayor of the small city of Madison, Wisconsin. Kennedy's first Secretary of HEW was Abraham Ribicoff, who had been a Governor of Connecticut, and left the Secretary's job to become a U.S. Senator from that State. According to Robert M. Ball, who was Commissioner of Social Security under Presidents Kennedy, Johnson and Nixon, neither Nestingen nor Ribicoff were much involved with the day to day running of HEW. It was Wilbur Cohen and another young Assistant Secretary who were the real powers at HEW. (16) When Celebrezze replaced Ribicoff in 1962, the roles among the players did not change appreciably.

So the key person among this triumvirate was really Wilbur Cohen. Cohen had an impressive pedigree on Social Security issues. He was a junior staffer on the original Committee on Economic Security created by FDR in 1934 to craft the Social Security program. After the Social Security Act was passed in 1935, Cohen became the first professional employee of the new Social Security Board created to administer the program. (17) He was the personal assistant to the head of the Social Security system, Arthur J. Altmeyer, for nearly 20 years. During the formative years of the Social Security system (1935-1953), Cohen served as the Social Security Administration's informal legislative liaison to Capitol Hill, at a time when this administrative agency was a major player in the making of Social Security policy. After the Eisenhower Administration came into office in 1953 Cohen was demoted, and eventually forced out in 1956. He went to the University of Michigan where he began a successful academic career. When Kennedy came into office in 1961 he immediately brought Wilbur Cohen back to Washington to serve in HEW as the Assistant Secretary for Legislation. President Kennedy would come to rely on Cohen to such an extent that he referred to him as "Mr. Social Security." (18) The Senator from Illinois, Paul Douglas, used to joke that in Washington a Social Security expert was anyone who knew Wilbur Cohen's phone number. (19)

In March 1964 stories appeared in the press suggesting Wilbur Cohen was thinking of resigning his position. Johnson called him on March 21st and gave him the flattering Johnson treatment:

Johnson: What the hell is this I read about you getting ready to resign on us?

Cohen: There wasn't any truth to that Mr. President.

Johnson: Well tell them it's a damned lie . . . I can't lose you. You've been with me long before I was President. I'd just as soon lose Mrs. Johnson. . . When you get ready to resign you let me know and you can take my place. I don't want you leaving here. You have meant too much all through the years." (20)

Earlier that same month Johnson had already called Celebrezze to complain about press leaks coming from HEW regarding LBJ's Medicare and poverty proposals. Already we see, in this conversation, signs of LBJ's rising dissatisfaction with some in HEW, although both the Secretary and Johnson complain about the leaks, and no suspects are mentioned. Celebrezze complains that Nestingen cannot get along with Cohen, and that kibitzers from Democratic headquarters are horning in on the Medicare work. The President concludes the conversation by telling Celebrezze, "you work it out, and fire somebody over there." (21)

Throughout 1964 the Administration suffers a series of setbacks in its efforts to get a Medicare bill through the Congress. It culminates in what might fairly be described as a debacle when the deadlocked Conference between the two houses adjourns, not only killing the Medicare program for 1964 but taking down with it the Social Security COLA and other Social Security provisions of the two bills.

Throughout 1964 it becomes increasing clear that Larry O'Brien and Wilbur Cohen have become the two key players for the Administration. Nestingen is never mentioned in connection with the Medicare developments, and Celebrezze does not figure very much in the President's conversations. And although O'Brien was, by virtue of his position, usually the one reporting legislative developments to the President, it was Cohen who was producing those developments (on the Administration side). O'Brien, in fact, was often merely passing along to the President what he had learned from Cohen. By early 1965 it is apparent that Wilbur Cohen has assumed a leading role, and in fact, it would be Cohen who in March 1965 would negotiate the critical deal with Chairman Mills to get a Medicare bill passed in Ways and Means. On April 1st Johnson calls Cohen to let him know he has been thinking about replacing key people at HEW, and that with success comes reward:

Johnson: Wilbur, I've been trying for a month or so to figure out some way we could shift our Undersecretary over there and we could take all your talents and move them into the Undersecretary's job, and then replace you with another man just like you, as competent as you are. Give you deserved recognition, a start up the ladder. . . . I've talked to a good many people about it, just feeling them out. Practically everybody I talked to feels about you like I do, that you have been superior in your work, that you ought to be the first one recognized by the Johnson Administration, because of what you have done this year and last year. . . I talked to the Secretary last night, and he said he would just absolutely be delighted, that you were the most competent, faithful and loyal man that he knew. . . That's the way I'm thinking and feeling." (22)

In fact, Johnson would elevate Cohen to the Undersecretary job and Nestingen would leave HEW. Celebrezze too would be replaced four months later by John Gardner. After serving as Undersecretary to Gardner for two and a half years, on March 1, 1968 Cohen became the seventh Secretary of HEW, serving out the last 10 months of the Johnson Administration. Although Cohen had no idea his tenure at the top would be so short, since everyone assumed Johnson was running for re-election. Cohen was in office barely 30 days before Johnson surprised the country by announcing he would not run for President.

Although many factors had to come together in the summer of 1965 to make enactment of the Medicare program possible, the rise of Wilbur Cohen to the role of key negotiator with the Congress was unquestionably one of the those factors. Cohen was an experienced hand in crafting legislation; he was a consummate negotiator; and he was an expert on the details of Social Security and health care, such that he could discuss policy options on the fly with Wilbur Mills and the subject matter experts in the Congress. In fact, he probably knew more than anyone in the Congress, including Mills, and for years had served Mills and others as an expert adviser. So he was in some very real sense the perfect man for the job. His rise, which we see hinted at in the tapes, is thus the simultaneous rise of the prospects of Medicare itself.

Lyndon Johnson was an enthusiastic trooper in Franklin Roosevelt's New Deal, and he was even a young protege of FDR, who, for reasons still not entirely clear, was unusually fond of Johnson and pushed his career far in advance of what would be expected with a young Congressman like Johnson. (23) But his real political roots were older, deeper, and closer to home. Johnson was a rural populist from the hardscrabble hill country of central Texas. His instincts were populist and his earliest political heroes were men in this tradition. His grandfather, Sam Early Johnson, was an unsuccessful political candidate for the turn-of-the-century Populist Party. Despite Huey Long being almost universally viewed as a demagogue, Johnson never spoke of Long in other than endearing terms, a fact which endeared him to Huey's son Russell Long, who would become an important Senator during the Johnson presidency. (24) Johnson understood Huey Long and his populist sentiments, and the two of them shared many of the same values. Johnson's first major political accomplishment, as a young Congressman, was bringing electricity to the hill country of his Texas home area. Although this was a classic New Deal TVA-like achievement, it was also a classic populist achievement and Johnson saw it in populist terms, as doing something for the poor hardworking farmers and their wives of the hill country.

Probably the most revealing conversation regarding LBJ's political values and sentiments as they related to Social Security and Medicare was an extended conversation he had with his Press Secretary, Bill Moyers. In this conversation, recorded on March 10, 1965, Johnson permits himself to reflect almost philosophically on his support for a provision in a pending bill which would provide a retroactive increase in Social Security payments. Moyers is arguing that the President should support the retroactivity clause because it will provide a stimulus to the economy. Johnson supports the provision, but he makes clear to Moyers that he does not see programs like Social Security and Medicare as being about economics.

Johnson: My reason though is not because of the economy. . . . my reason would be the same as I agreed to go $400 million on health. I've never seen an anti-trust suit lie against an old-age pensioner for monopoly or concentration of power or closely-held wealth. I've never seen it apply it to the average worker. And I've never seen one have too much health benefits. So when they come in to me and say we've got to have $400 million more so we can take care of some doctors bills, I'm for it on health. I'm pretty much for it on education. I'm for it anywhere it's practicable. . . . My inclination would be . . . that it ought to retroactive as far back as you can get . . . because none of them ever get enough. That they are entitled to it. That's an obligation of ours. It's just like your mother writing you and saying she wants $20, and I'd always sent mine a $100 when she did. I never did it because I thought it was going to be good for the economy of Austin. I always did it because I thought she was entitled to it. And I think that's a much better reason and a much better cause and I think it can be defended on a hell of a better basis. . . . We do know that it affects the economy. . . . it helps us in that respect. But that's not the basis to go to the Hill, or the justification. We've just got to say that by God you can't treat grandma this way. She's entitled to it and we promised it to her." (25)

President Johnson rarely missed an opportunity to put in a little lobbying on behalf of his Medicare proposal. Almost routinely, he would mention it whenever he talked with anyone who he thought might be helpful. Throughout 1964 and 1965 the White House Tapes contains dozens of conversations with policymakers and legislators in Johnson's efforts to push his bill along.

To illustrate just how important Johnson saw the issue as being, and how relentless he could be when he wanted something, on February 10, 1964 he called Representative Frank Thompson of New Jersey to congratulate him on passing the Civil Rights Act of 1964 through the House. This was one of the most important milestone accomplishments of Johnson's Great Society. But he would not pause long enough to enjoy much of a sense of triumph. In the same breath, he congratulated Thompson and made sure that Thompson could not catch his. Johnson told him, "I'm mighty proud of you, it's a great day in the House. I'm mighty proud of you. Let's wrap up medical care now and we'll really be going." (26)

In the same March conversation in which he chided Wilbur Cohen for the talk of his resigning, he told Cohen: "Has Wilbur Mills ever got with you yet?. . . I'll get with him Monday again. I want to say to the auto workers that we are going to spend all summer here passing civil rights, and we are going to spend the rest of our lives if necessary passing medical care." Early in 1964 it looked for a time like Medicare was finally going to move in Ways and Means, but by the summer the portents had gotten considerably bleaker and it began to look like the President might well have to spend the rest of his life trying to get medical care passed.

The Debacle of 1964-

There were basically two bills in the Congress at the same time: King-Anderson, which was the Medicare bill the Administration preferred and Kerr-Mills which involved would become Medicaid (which was being pushed by Wilbur Mills and which was generally favored by many Republicans). On May 18, 1964 Larry O'Brien had a long conversation with Johnson about their legislative strategies for pushing King-Anderson. It was clear Mills was being cagey with them, not tipping his hand but still managing to get the Administration's hopes up. O'Brien advised the President,

O'Brien: Cohen says that from everything he can discover that there is no hanky-panky, they said some of the strong Medicare supporters on the Committee have gotten a little nervous-Al Ullman, for one, an awfully decent guy on the Committee-talked to me last week and he said "I just have a feeling something is going to work out but I get nervous because Mills won't tell us anything.". . . the consensus is that Mills is going to come out with a Kerr-Mills Social Security package that bypasses Medicare . . . Mills of course insists that isn't what he intends to do.

Johnson (very subdued): Tell him tomorrow that I would like to talk to him about it as soon as he gets where he can, and I sure hope . . . he makes no commitments until we talk about it.

They then discuss stories in the newspapers which report the Committee is considering a Social Security COLA of 6%. The stories are very detailed, and after reading one news clipping an exasperated Johnson tells O'Brien,

Johnson: Tell him goddamnit if they are getting to where that's getting out I'd like to know what he has in mind. They're asking me questions and I don't know what the hell they're doing. A Democratic President out to know what a Democratic Chairman is doing. Just tell him that. (27)

Three weeks later, on June 9th, Johnson records a conversation with Mills. This could have been an opportunity for Johnson to find out where things stood, but he was careful not to trespass on Mills' prerogatives as Chairman, and the two circle around each other like a couple of old bulls, neither letting the other know his real intentions. Johnson never asks Mills what his plans are, and he never tells Mills what he wants. They discuss Medicare only obliquely, as Johnson urges Mills forward.

Johnson: The most important thing is the bill you're working on. If you get something you can possibly live with, and defend, and these people will not kick over the bucket with, that will mean more than all the bills we passed put together. And I think it will mean more to posterity, and to you, and to me. So I'm not trying to go into details. And I'm not trying to write a new section every morning or a new title. I just let it go since the last time I talked to you. But I've looked at some of the stuff that's being considered, from the press and other people, and it looks like to me that you're approaching it right, and you're getting it in shape. And I just say this. There is not anything that has happened in my six months, or that will happen in my whole term, in my judgment, that will mean more to us as a party, or me or you as individuals than this piece of legislation. . . . You work it out, and anything you want me to do, let me know . . . Let's make it sound and solid. But let's move in this direction. And it will be a bill that you and your folks will never forget. And I'll come in and applaud you.

Mills: We're making every effort to do something.

Johnson: Well grind something out of there. And let me know anything that I need to know.

Mills: Alright sir. (28)

While this political minuet was being danced out, the Administration decided to put a few eggs outside Mills' basket. Two days after this conversation with Mills, Johnson has a conversation with former Kentucky Senator Earle Clements where they discuss the possibility of bypassing the House and trying to add Medicare as an amendment in the Senate. (29) On June 22nd O'Brien reports to the President that the "situation has deteriorated" and now Mills is suggesting he might report out a bill without any medical care provisions and that the Administration can seek to have them added in the Senate. Johnson concurs that this is apparently their only open option. O'Brien advises that Mills will go along but will insist that it is their job to get the House sponsors to withdraw their medical care amendments. O'Brien also warns Johnson that Mills is not really promising to help get Medicare through the Conference. (30) Two weeks later Representative King moves to withdraw King-Anderson in the Committee, and Ways and Means passes out a bill (H.R. 11865) containing only the Social Security benefit increase, without Medicare.

When the bill got to the Senate, the Finance Committee was not disposed to give it much consideration either as both the Chairman, Russell Long, and several of the influential members were know to be opposed. On August 1st Committee member George Smathers of Florida called Johnson to advise him that he didn't think Medicare could pass in the Finance Committee. Smathers suggested that the best political strategy would be to let it be killed so Johnson could use it as an election issue against Goldwater. Johnson resisted this idea. Smathers admitted that Wilbur Cohen had been lobbying him but that since his opposition was well-known he couldn't simply change his position without some form of political cover. He told Johnson he would need Committee hearings at a minimum before even considering reversing his position. Subsequent to this conversation, the Administration lobbied for hearings, which took place in August. But the Finance Committee, like Ways and Means, would not vote out King-Anderson. (31)

But in the Senate the rules are freer than in the House. Smathers called Johnson back three days later and told him the strategy would be to offer King-Anderson on the floor as an amendment. If it passed the Senators could then go to Conference with the House and agree to settle for a substitute being offered by Senator Ribicoff of Conneticut, as a kind of half-way between King-Anderson and the House position. (32) Johnson indicates he is willing to accept such an approach. On August 14th, O'Brien calls the President and asks for guidance. Johnson gives him fairly explicit instructions to support the Smathers strategy.

Johnson: I would be prepared to have nothing rather than not have Medicare. If you could put it on in the Senate-King-Anderson-I'd go to the Conference. And I'd let Wilbur (Mills) scare the living hell out of the doctors and everybody else, then he could come up with a compromise and say, well you can make your choice, between getting this extra money and having health insurance. And I think you would establish the first health insurance that way, if you could get it over. (O'Brien suggests the option of moving the Ribicoff provision in place of King-Anderson on the Senate floor.)

Johnson: Well if you move that and get it taken out, you'll have nothing to trade on. If you move with King-Anderson there you can trade for Ribicoff. . . . I'll tell you this, Wilbur Mills will take your pants off unless you've got something that he's got to trade for. (33)

King-Anderson was offered as an amendment on the floor, with Ribicoff in reserve. (34) At the last minute Senate Majority Leader Mike Mansfield called Johnson on September 2nd to caution that there may not be enough votes to pass Medicare on the floor-he counts only 51 in favor, and that includes the Democrat Carl Hayden of Arizona, who is actually against the bill, but Mansfield says Hayden will switch if Johnson calls him personally. Johnson calls Hayden later that day, telling him that Medicare is necessary for the party's prospects in the November election. (35) There follows a flurry of phone calls, with some callers advising Johnson the vote will be lost, others that it will be won. Later that same day (September 2nd) the bill passes the Senate on a vote of 49 to 44-with King-Anderson as the Senate position.

Already by the next day the Johnson strategy had become to unravel, due to a greedy overreaching by the Administration. To gild the lily the Administration had begun suggesting that the House vote to instruct the Conferees to recede to the Senate position on Medicare in the Conference. This would have meant two things: it would have meant King-Anderson would prevail, violating the strategy that key Democrats in the Congress (including Mills) were expecting the Administration to pursue; and, perhaps even worse, it would undermine Mills' authority because it would mean that the Administration had gotten Medicare to pass the House without Mills' consent. This proved to be a bad misstep. Mills immediately rallied opposition to the idea and the Administration had to back down-with, it turned out, fatal results for their earlier strategy. When the two bills got to Conference, Mills refused to accept any medical care provision of any kind. Johnson insisted that the Senators insist on some form of medical care program, with the result being a deadlocked Conference, as previously recounted. (36)

1965: A New Political Mandate-

Following the Presidential election of 1964, and Johnson's huge landslide victory, he came into 1965 with a clear mandate for his programs and a large Democratic base in both houses of Congress. (37) Conditions were optimal for Medicare. If it could ever pass, 1965 should be the year.

In a conversation with the new Vice President, Hubert Humphrey, in the first week of March 1965, Johnson chews out his team, with Humphrey taking the brunt, for the absence of any major legislative achievements yet in 1965. He tells Humphrey,

Johnson: "They are bogged down. The House had nothing this week-all goddamn 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. (38)

While all this is going on, the Administration's new bill is being worked on in the House Ways and Means Committee. Wilbur Cohen is directly negotiating with Mills in yet another effort to move the great immovable object. But the election changed not just the Democrats advantage over the Republicans, but Mills too apparently saw the writing in the returns. As Peter Corning put it in his history of Medicare: "Just after the election, Chairman Mills made another speech, in which he announced: 'I can support a pay-roll tax for financing health benefits just as I have supported a payroll tax for cash benefits.' Reading between the lines, what Chairman Mills seemed to be saying was that the Johnson landslide had clearly settled the issue, and he would accept the decision that had been made at the polls." (39)

On March 23, 1965 the breakthrough finally comes. In a phone call at 4:54 in the afternoon Cohen joins Mills, Speaker of the House John McCormack, and House Majority Leader Carl Albert, in a conference call to Johnson. They inform him that Medicare has just passed out of the Ways and Means Committee by a vote of 17 to 8. In this remarkable conversation, Cohen informs the President, apparently for the first time, just what he has agreed to in the President's name. This is the moment that Lyndon Johnson realizes that Medicare is destined to pass, and he learns for the first time just what his Medicare program will and will not include.

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. (40)

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 physicians 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 doctors 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% . . . 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 physicians 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. (41)

With Wilbur Mills and Ways and Means on board, the bill was destined to pass. But this did not mean that no further efforts were needed. The White Tapes contain several more conversations regarding legislative strategy and generating public support for the bill before it finally passes (in the House in April, in the Senate in June, and in the Conference in July). Russell Long in the Senate tried one last time to block Medicare by proposing various medical plans of his own, but sentiment in both houses was strongly in favor.

The conversation that is again the most revealing of Johnson's manner, his populist sentiments, and his driving ambitions, is a conversation with Larry O'Brien on April 9th where he instructs O'Brien on how to sell the bill on Capitol Hill. Johnson is anxious to move enough bills so that he can claim in his first 100 days to have passed more bills than FDR in his famous first 100 days. And he counsels O'Brien to sell Medicare as an historic achievement.

Johnson: The second thing to put out is that every guy that votes for Medicare and education, his grandchildren will say my grandpa was in the Congress that enacted these two. . . . So it makes 'em proud. And they can go back home and say I was one of the 54, or my daddy was one of the 54 . . . so all his children and grandchildren are bragging about being one of the 54. (42)

The final scene in the play, already described, was the formal signing ceremony in Independence on July 30th. The last conversation in the Medicare sequence then is a call Johnson makes to Harry Truman on July 27th. Obviously, Johnson is trying to ascertain Truman's availability for a ceremony in Independence, although he never really lets Truman know this is his intention. It is not clear whether Truman knows why Johnson wants to come see him. With only three days before the signing ceremony it seems awfully late to be uncertain as to Truman's availability.

Johnson: You feel like my coming out to see you anytime soon?

Truman: Any time you say.

Johnson: I'll give you a day's notice, and I thought maybe I would just fly out there sometime in the next week or ten days.

Truman: Whenever you come I'll be available. Let me know ahead of time, and I'll be sure and be here.

Johnson: I'll call you and I'll just come visit with you and have a little talk with you.

Truman: Whenever I'm in the presence of the President he does the talking, I don't.

The passage of Medicare would be one of the lasting achievements of Lyndon Johnson's presidency and a key enduring pillar of the Great Society. While the general outline of Medicare's legislative history had been well-known for some time, the recent releases of Lyndon Johnson's secretly recorded White House phone conversations throws some new light, and adds some additional nuances, to this broad story. We see, for example, more clearly than previously appreciated the key role that Wilbur Cohen played in the successful campaign for Medicare's passage through Congress. We hear Lyndon Johnson express the populist sentiments which inform his commitment to programs like Medicare. We see some of the ups and downs and uncertainties of the legislative process with a clarity that is lost in a simple listing of key dates of the passage of bills through the various stages of the legislative process.

At the end of his presidency, Franklin Roosevelt was reported to have considered the Social Security Act of 1935 to be the proudest domestic achievement of his political career. It is unknown whether Lyndon Johnson saw Medicare as his. But one thing is certain which both Presidents had in common. Social Security would not have been enacted in 1935 without Franklin Roosevelt in the White House, and Medicare would not have been enacted in 1965 if Lyndon Johnson had not been President. They both were the indispensable right man for the right time.

1. Harry Truman's Medicare Part B application form, along with that of Mrs. Truman, are on display in the history museum of the Social Security Administration (SSA) in Baltimore, Maryland. President Truman's application form can also be viewed on the SSA website at: http://www.socialsecurity.gov/history/lbjsm.html A videoclip of the Johnson/Truman interaction can also be found on the SSA website at: http://www.socialsecurity.gov/history/mpeg/videosound.html#9

2. Poverty among the elderly was at 35.2% in 1959, down to 24.6% by 1970, and stood at only 10.2% in 2000. This huge reduction in poverty among the elderly is generally believed to be due to a combination of Social Security cash benefits and Medicare coverage. Whereas, the elderly used to have the highest rate of poverty among age cohorts, today children do, and the elderly are the most prosperous cohort. Cf., Table 3E2, Social Security Administration Annual Statistical Supplement, available online at: http://www.socialsecurity.gov/policy/docs/statcomps/supplement/2002/3e.pdf

3. See the SSA website at: http://www.socialsecurity.gov/history/hststmts.html

4. For a detailed account of political development of Medicare see the book The Evolution of Medicare: From Idea to Law, by Peter A. Corning. Published on the SSA website at: http://www.socialsecurity.gov/history/corning.html Chapter 3 describes the period covering the Truman presidency.

5. A brief clip of Ewing appearing on the Longines Watches TV program can be found on the SSA website, Medicare & Medicaid Clip #4 at: http://www.socialsecurity.gov/history/mpeg/videosound.html (undated)

6. Cf. videoclip Medicare & Medicaid Clip #5 on SSA website at: the SSA website at: http://www.socialsecurity.gov/history/mpeg/videosound.html (undated)

7. The idea that women would qualify for Medicare at a younger age than men has never been part of Medicare. Coverage of prescription drugs under Medicare was very briefly available as part of the failed Catastrophic Medical Care bill of 1987, which was repealed within a year of enactment. Medicare coverage of the disabled was not added to the program until 1972.

8. Cf. videoclip Medicare & Medicaid Clip #5 on SSA website at: the SSA website at: http://www.socialsecurity.gov/history/mpeg/videosound.html (undated)

9. Cf. videoclip Medicare & Medicaid Clip #6 on SSA website at: the SSA website at: http://www.socialsecurity.gov/history/mpeg/videosound.html (undated)

10. Telecast to the nation, July 17, 1962; text available on SSA website at: http://www.socialsecurity.gov/history/jfkstmts.html

11. Videoclip from "A Brief History of Medicare and Medicaid," U. S. Health Care Financing Administration, December 1995. Available in the SSA History Archives at SSA headquarters in Baltimore, Maryland.

12. The text of Reagan's canned speech can be found as an Appendix in Skidmore, Max, Social Security and Its Enemies: The Case for America's Most Efficient Insurance Program, Westview Press, 1999.

13. The Senate health care provision was part of a bill to provide a 10% Social Security COLA, which Mills and the House Democrats wanted. But the Senate held firm to the position that they would not vote for the benefit increase without the health care program being part of the deal. The impasse could not be broken and neither side would compromise. Thus, in a very rare event in the history of the Congress, the Conference reported that it was hopelessly deadlocked and the Social Security bill was allowed to die.

14. Beschloss, Michael, Taking Charge: The Johnson White House Tapes, 1963-1964, New York, Simon and Shuster, 1997. Beschloss, Michael, Reaching for Glory: Lyndon Johnson's Secret White House Tapes, 1964-196, New York, Simon and Shuster, 2001. The tapes are available for purchase from the LBJ Presidential Library (see their website at: http://www.lbjlib.utexas.edu/johnson/archives.hom/archives-main.shtm). A complete set of the LBJ Tapes is also available and open to researchers at the Social Security Administration History Archives in Baltimore, Maryland.

15. All conversations quoted here are from the SSA website at: http://www.socialsecurity.gov/history/LBJ/lbj.html The tapes as issued by the LBJ Library are designated by a code, such as WH6403.15, which in this case indicates a White House recording made in March 1964, and it is recording number 15. There will often be multiple conversations on a single tape, not all related to the same topics.

16. Oral History Interview with Robert M. Ball, Interview #3, April 3, 2001. Interview by this author; available on the SSA website at: http://www.socialsecurity.gov/history/orals/ball3.html

17. Initially, a three-person Social Security Board was the administrative agency responsible for the programs under the Social Security Act. In 1946, as part of a larger federal reorganization, the Social Security Board was replaced by the Social Security Administration, with a single Commissioner as its head. The organization was unchanged, except for this shift at the very top. So, depending upon which point in time is under discussion, it is either the Social Security Board or the Social Security Administration which is involved, but in either case it is the same organization.

18. The definitive biography of Cohen is Berkowitz, Edward, Mr. Social Security: The Life of Wilbur J. Cohen, University of Kansas Press. 1995. See also my review of the Berkowitz biography at: http://www.socialsecurity.gov/history/ldwbook1.html

19. Cf. "Wilbur J. Cohen: The Under Secretary," OASIS, August 1967, available online at: http://www.ssa.gov/history/cohenoasis.html

20. Cf. tape WH6403.15

21. Cf. tape WH6403.05

22. Cf. tape WH6504.01

23. The relationship between Johnson and FDR is discussed in insightful ways by Robert Caro in his masterful work, Master of the Senate: The Years of Lyndon Johnson, New York, Knopf, 2002.

24. Cf., for example, tape WH6411.24 where in the context of a raw political appeal by Russell Long to have Johnson intervene to prevent closing of an Army base in Louisiana, Long makes reference to "the kind things you said about my daddy."

25. Cf. tape WH6503.05.

26. Cf. tape WH6402.14

27. Cf. tape WH6405.08

28. Cf. tape WH6406.03

29. Cf. tape WH6406.06

30. Cf. tape WH6406.12

31. Cf. tape WH6408.01

32. Cf. tape WH6408.05. Ribicoff's compromise provision would have allowed Social Security beneficiaries to have a choice between a medical care package or slightly increased Social Security benefits. This would have the effect of making the new Medicare program voluntary, which, Ribicoff thought, would ease some of the opposition.

33. Cf. tape WH6408.19

34. This strategy was of course a secret one. It was essential that only a few people knew what the Administration was planning. Ribicoff, for one, was difficult to keep on board because he kept trying to persuade his colleagues to support his amendment at the outset, and he put pressure on the Administration by issuing press releases and so on.

35. In the 1962 vote on Medicare Hayden waited to vote last, agreeing to support the Administration only if his vote was the deciding one for passage. Johnson asked him to take the same posture about this 1964 vote.

36. As the Conference came apart at the seams Johnson had a series of phone conversations with the key players. Cf. tapes WH6409.10 and WH6409.15

37. Johnson's popular vote margin (61% to 39% for Goldwater) was the largest in American history (and remains so). The Democrats picked up 41 seats in the House and won 28 of the 35 seats up for election in the Senate. Not only were the margins impressive, but this would be the most liberal Congress since the New Deal.

38. Cf. WH6503.02

39. Corning, op. cit., Chapter 4. Available online at: http://www.socialsecurity.gov/history/corningchap4.html

40. This remark refers to one of the key ideas which emerged from the discussions with Mills. This was the idea of creating a program with two parts, Part A, which would be mandatory hospital insurance, and Part B, which would be optional supplemental coverage for doctors bills. It is this new idea of separate coverage for doctors bills (which will be partly subsided by the Treasury) which adds this new net cost.

41. Cf. tape WH6503.11

42. Cf. tape WH6504.04

43. Cf. tape WH6507.08