So why did Medicare itself start so smoothly?
... The administration's initial response [to complaints about the new Medicare prescription drug program] will be familiar to anyone who recalls the early months of the Iraqi insurgency or the first few days after Hurricane Katrina. "This is going very well," a spokesman at the Center for Medicare and Medicaid Services (CMS) said on January 4, with apparent seriousness. When the difficulties became too widespread for even the Bush administration to ignore, officials fell back on another well-rehearsed excuse: Glitches were inevitable given the nature of the task. "We know there are going to be bumps in the road," another CMS spokesman said. "It's a new program."
Most people probably think this makes sense, since most people think that the government always bungles such massive undertakings anyway. But consider what happened when the Johnson administration rolled out Medicare for the first time in July 1966. Back then, the obstacles were even more daunting than they are today. Rather than simply adding a benefit for a relatively narrow class of services (prescription drugs), introducing Medicare meant establishing an entirely new insurance program in just eleven months. There were concerns about hospital capacity: What if seniors held off on medical treatment until the benefit kicked in and then flooded facilities? There were also racial complications: LBJ had insisted that Medicare refuse payments to hospitals that didn't abide by federal civil rights guidelines. Since many Southern hospitals remained segregated, senior citizens there might have had no place to go.
So what happened on the day that this complex program was implemented? Thousands of senior citizens simply went to the hospital and got the health care they needed. "There were no crises that I remember," says Yale University political scientist Theodore Marmor, who worked in the office overseeing Medicare implementation and went on to write The Politics of Medicare, the program's definitive history. Newspaper accounts from the '60s back him up. Under the headline "medicare takes over easily," a Post writer described the program's first day as "a smooth transition, undramatic as a bed change." Three weeks later, the Times affirmed that "medicare's start has been smooth."
What did Johnson do right that Bush did wrong? Start with the people he put in charge. Today, the man directly responsible for Medicare is Mark McClellan, a physician and former Stanford economist. Though hardly a Michael Brown, McClellan has no prior experience when it comes to implementing social insurance programs. (His predecessor, Tom Scully, left CMS to become a lobbyist almost immediately after the Medicare bill passed.) The man Johnson tapped to run Medicare was Robert Ball, a longtime civil servant who had worked his way up through the Social Security Administration starting in 1939. He and other veterans helped design the program--urging, among other things, that the law take effect in summer, when hospitals would be least crowded.
Another difference between the two administrations is their willingness to take initiative. Last year, experts repeatedly warned the Bush administration that it had inadequate contingency plans in place, culminating in a December Government Accountability Office report that predicted with eerie accuracy exactly what has happened at pharmacies around the country these past two weeks. LBJ's team was far more cautious. Although confident that hospitals could handle any potential surges, it still drew up plans for transferring patients to overflow facilities, even lining up helicopters in Texas to provide speedy transport.
Granted, senior citizens probably need more hand-holding in 2006 than they did in 1966, because the new law channels its drug coverage through private insurance companies from which beneficiaries must choose. But that, too, is a distinction: While Bush talks of "choice" as his plan's greatest virtue, seniors seem bewildered by having to pick from as many as 52 different prescription plans, each one with different premiums, cost-sharing requirements, and lists of drugs covered. By contrast, Johnson administration officials had argued against inundating seniors with such options. "I would not have dreamed of going about this in a way that meant individuals had to choose from among all these possibilities," Ball says today. "I would have expected chaos."
And, from Maine to California, chaos is just what the Bush administration has gotten. ...