The term "
entitlement" originally referred to aristocrats. Aristocrats had titles, and they thought that they were thereby entitled to various things, particularly the deference of the common people. Everyone else, by contrast, was dependent on the aristocrats.
America Before the Entitlement State
In 1962, the highest mass standard of living in the world was definitely not shared by all. There was "another America": 40 to 50 million citizens who were poor, who lacked adequate medical care, and who were "socially invisible" to the majority of the population. Within this poverty-stricken group were more than 8 million of the 18 million Americans who were 65 years of age and over, suffering from a "downward spiral" of sickness and isolation. And although there were half a million Americans in nursing homes, less than 60 percent of the homes were considered acceptable (Harrington, 1962). Medicare was formed in a society with idealistic expectations of wealth for all-at least for all of those who "deserved" it yet increasingly isolated its minorities and its poor.
There were evident rifts in American society in the early 1960s, by race, age, class, and gender. Demographic changes after World War II had created communities filled with contrasts. The flight of relatively young, affluent, middle-class families to new suburbs created inner cities with disproportionate numbers of elderly and minority Americans. The stage was set for summers of racial violence, urban decay, and declining tax revenues for city schools, hospitals, and social services. In cities such as Newark, New Jersey, and Washington, DC, African-Americans represented a majority of the population by the early 1960s. Physicians migrated to the suburbs with other white-collar workers, leaving the hospital emergency room as a primary source of care for many urban dwellers. Emergency department visits increased by 16 million, or 175 percent, between 1954 and 1964, and the quality of care was often tenuous. Among the complaints: Physicians were overworked; they were reluctant to take on weekend and evening duty; and as suburbanites beset by worsening traffic conditions, they could not respond promptly to emergency calls (Silver, 1966).
Wider social rifts permeated the structure of health care and its institutions. These too were often socially "invisible"; that is, taken for granted and commented on rarely until the late 1950s. Herbert Klarman (1962) did a study of hospital patients in 1957 that described the rigid pattern of stratification and segregation by class and race in New York City. In New York's for-profit hospitals and in the private and semi-private accommodations of notfor-profit hospitals, patients designated "white" were virtually the only patients (97 percent and 96 percent, respectively). The wards of not-for-profit hospitals provided accommodations for poorer (or uninsured) members of society; here the proportion of white people was lower (66 percent). But in the municipal hospitals, the backbone of welfare medical care, the great majority of patients were Puerto Rican, African-American, and members of races other than white (Klarman, 1962). In the South, there was formal racial segregation, although this was beginning to be challenged effectively. "Disease and Death Know No Race" proclaimed the signs carried by protesters at the Grady Hospital in Atlanta in 1962, where a group of African-Americans had taken over the lounge of the "whites-only" outpatient clinic (Newsweek, 1962).
The contrast between wish and reality (the wish for a truly Great Society and the reality of conflict and division) forms an essential first theme for understanding the years before Medicare. In effect, Medicare was to be a means of transforming the elderly into paying consumers of hospital services. Medicaid, with its continuing welfare stigma, was to cover those who were "indigent." Legislative proposals from the first Forand bill in 1957, through the Kennedy-Anderson proposals, to the signing of the Medicare legislation in July 1965, stressed the inability of the private market to meet the needs of older, retired Americans who could not afford medical care when they were sick, rather than the needs of all Americans who were uninsured. As a group, the elderly were significantly poorer than the working population, their medical needs were much greater, and insurance coverage, where it did exist, included only a minority of total health care costs.'