Medicare and Medicaid turn 60 – and face historic cuts decades in the making

The Guardian

4 days ago

The US's largest public health insurance programs, Medicare and Medicaid, turn 60 years old on Wednesday – a birthday that will be celebrated only weeks after Republicans enacted the largest cuts to healthcare in the nation's history.
Passed in the civil rights era, the sister health insurance programs served as tools for the Democratic president Lyndon Johnson to desegregate American healthcare and fight poverty.
'This is an infamous day for the US, which already has the most abysmal healthcare system among our peer nations,' said Lawrence Gostin, a professor of global health law at Georgetown Law. 'Now, in order to give tax relief and spend more on defense, we're kicking off our most needy citizens from life-saving care.'
In a health system defined by a patchwork of public and private coverage, Medicare and Medicaid have stood for 60 years as the civil rights era's health legacy – their history more often marked by expansion than contraction, even amid decades of attacks from conservatives.
That history took a sharp right turn on the Fourth of July, when Donald Trump signed a Republican budget law that will cut $1tn from Medicaid beginning in 2026.
'It's really unconscionable these cuts,' said David Lipschutz, co-director of the Center for Medicare Advocacy, speaking about both programs. 'The magnitude, the scope, the targeting of certain lawfully present immigrants, the added requirements and burdens for people with Medicaid – specifically designed to purge the roles of people who would otherwise be eligible.'
Today, Medicare insures more than 68 million seniors, and Medicaid insures 71 million low-income, elderly and disabled adults. Cuts signed by Trump are expected to result in nearly 12 million people losing Medicaid coverage and another 5 million people losing health insurance because of a reduction in government subsidies to private insurance, through so-called 'Obamacare' plans.
The cuts are the largest in the program's history, and enact decades of conservative rhetoric – tracing all the way back to then-actor Ronald Reagan's 1961 criticism of public health insurance as 'socialized medicine'.
Medicare and Medicaid were enacted together on 30 July 1965 – born with Johnson's signature on the Social Security Amendments of 1965, or HR 6675.
The programs represented both an enormous victory and, in a way, a concession. A group of campaigners for universal health coverage tried and failed to pass a 'national health insurance' after the second world war – in large part because of the antagonism of American doctors – around the same time that the United Kingdom's National Health Service was getting off the ground.
Unable to achieve universal coverage, proponents settled for an 'add-on' to social security, the retirement benefit for older Americans, according to Pulitzer prize-winning author Paul Starr, whose book, The Social Transformation of American Medicine, is the authoritative history.
'Medicaid was a footnote,' said Starr. 'The whole focus was on passing Medicare.'
Medicare also sought to correct a searing injustice in American healthcare – Jim Crow segregation that extended to America's doctor's office and hospitals. In 1946, congressional lawmakers modernized the nation's healthcare facilities with the Hill-Burton Act, but did so with a 'separate but equal' philosophy. For nearly two decades, Hill-Burton helped construct or modernize 6,800 facilities in 4,000 communities, often excluding Black patients and physicians.
'Typical practice in the south would be to see all the white patients first, and see the Black patients last,' said Starr. 'Hospitals were segregated and Black people did not have access to mainstream hospital care in many places.'
A 1963 supreme court case against a North Carolina hospital found that the 'separate but equal' doctrine was unconstitutional. In a few short years, hospitals and clinics across the country desegregated to participate in Medicare.
Less recognized at the time was the power of Medicaid, and how its structure – jointly operated by the states and federal government – would make it more vulnerable to political attacks.
'Medicaid gradually grew to being the system of health insurance for low-income people, for people with disabilities. It became the method of financing nursing homes in the US,' said Starr.
Medicare and Medicaid led, 'not only to desegregating, but elevating life expectancy across the states and reducing disparities among racial and ethnic minorities, women, children and older adults and people with disabilities,' said Daniel Dawes, an expert on global health policy at Meharry Medical College.
Beginning in the Reagan era in the 1980s, conservatives proposed transforming Medicaid from an 'entitlement', which does not cap costs, to a limited 'block grant' to states – necessarily capping how many people and what services would be covered.
The former House speaker Newt Gingrich, George W Bush's administration and the former House speaker Paul Ryan, all Republicans, made proposals to block-grant Medicaid.
Decades of rhetoric pushing to cut Medicaid carried into talking points about the One Big Beautiful Bill Act, Trump's signature spending bill. Trump officials rolled out vintage Republican arguments to describe Medicaid beneficiaries as caught in 'a lifelong trap of dependency'.
A wide array of evidence shows most Medicaid beneficiaries who can work already do, and new requirements instead function as red tape to limit enrollment. Polls show that Medicaid is widely popular, even among Republicans.
The Obama administration led a historic expansion of Medicaid in 2010, through the Affordable Care Act (ACA), better known as Obamacare. For the first time, Medicaid would cover working-age single adults – not just pregnant women or families, as the program had traditionally done.
In 2025, a major economic study again showed its benefits: expanding Medicaid to millions more Americans probably saved more than 27,000 lives.
The improvement in Americans' health was perhaps only matched by the ferocity of attacks from the political right. For nearly a decade, the repeal of Obamacare became a cornerstone of Republican politics.
Trump himself has only sporadically engaged in the healthcare debate. In 2017, he would tell the press: 'Nobody knew that healthcare could be so complicated.' Before he was elected again in 2024, he said he had 'concepts of a plan' to replace Obamacare, and promised not to touch Medicaid, Medicare or social security.
Trump first attempted to repeal Obamacare in 2017, a change that would have left an estimated 15 million people without insurance. The bill was memorably tanked with a thumbs-down from the Republican senator John McCain.
However, ideas about how to cut Medicaid did not sink with the bill. In 2018, the Trump administration approved the first Medicaid work requirements as pilots in Arkansas and Georgia. Courts struck down those pilots, but they now form a critical part of how the One Big Beautiful Bill Act is expected to push people off the program.
Starr described the cuts to Medicaid as out of step with reality.
'A lot of people do work at the minimum wage, millions of people, and they're still poor,' he said. 'And by the way those minimum-wage jobs won't provide them any healthcare – so you're just going to let them die when they get sick? What are you going to do?'
The enormous cuts to Medicaid have set off new wrangling within the Republican party, including efforts by the Missouri Republican senator Josh Hawley to repeal the cuts for which he just voted.
Republicans could face further backlash when cuts to Medicaid start to hit rural hospitals around 2026. A June analysis by the University of North Carolina's Sheps Center for Health Services Research found that 338 rural hospitals, including dozens in states such as Louisiana, Kentucky and Oklahoma, could close as a result of the spending bill. There are nearly 1,800 rural hospitals nationally, according to the Kaiser Family Foundation (KFF), a healthcare research non-profit.
'While we've tried to chip away at Medicaid for many, many decades this is the first time Congress has really gutted the program,' said Gostin. 'People will die, a lot of people will die. A lot of people will get very, very sick, have preventable illnesses, and so to me this is just simply historic and unconscionable.'