By Walter Tsou, M.D., M.P.H.
The Philadelphia Inquirer, July 30, 2025
Sixty years ago today, President Lyndon Johnson signed into law the two most consequential health programs in U.S. history — Medicare and Medicaid. Both Medicare (Title 18) and Medicaid (Title 19) were added to the Social Security Act with benefits directed at seniors.
For seniors no longer in the workforce and those who were chronically disabled, Medicare, along with Social Security, were the programs that allowed the elderly not to fall into abject poverty at a time when their health worsened.
Medicaid was created from the federal-state partnership of the 1960 Kerr Mills Act, but Congress expanded the age limits of eligible low-income populations to include families with children, people with disabilities, and the blind.
Wilbur Cohen, undersecretary of the Department of Health, Education and Welfare under Johnson, is considered the father of these two essential programs. Cohen envisioned a national health insurance program for America, but, given the power of the medical and insurance lobby, had to settle for Medicare for seniors and Medicaid for low-income citizens. He likened the final legislation to the salami approach, where he would accept one slice at a time until he could get the whole salami.
Sixty years later, we are still waiting.
The contribution of Medicare and Medicaid to American life cannot be overstated. Today, all seniors with 40 quarters of Medicare taxes paid, those with chronic disabilities, ALS, and patients on dialysis, are covered by Medicare. We only need to imagine if coverage had not been expanded, what a difference it would make to family finances, work productivity, or premature mortality.
Almost one in four Americans is on Medicaid, including over 40% of children. The proposed work requirements and new paperwork verifications needed to retain Medicaid —thanks to the recently enacted “big, beautiful bill” — will make our current bureaucratic and dysfunctional approach to healthcare financing even worse — actually far worse.
In Arkansas, a work requirement cost the state $26 million without any increase in employment or volunteer time. Even worse, more than 18,000 lost health insurance coverage. Now multiply the new unfunded mandate on each state government that must verify this new onerous paperwork requirement, and add the millions who are predicted to lose their health insurance, and you realize that we are moving dramatically away from the original intent of Medicare or Medicaid.
Despite the belief that markets are more efficient, in healthcare, it makes it much more cumbersome and dysfunctional.
In 1948, the Universal Declaration of Human Rights was adopted by the U.N., including the United States. Article 25 states that “everyone has the right to a standard of living adequate for the health and well-being of himself and of his family.” Two points should be emphasized. Everyone means that if you can breathe, regardless of your position in life, a society has a basic level of care that is provided to you. Second, universal health insurance or access to care is essential for health.
Beyond the recognition that healthcare is a human right, it is a necessity for a productive society. Our taxes are dependent on people well enough to work, play, and worship. Keeping people insured keeps them well. Keeping them well keeps our society productive.
We have unfortunately believed that market forces can solve all that is wrong in healthcare. Some think we can solve our labor shortages by forcing the few “able-bodied” to be required to work or by denying emergency care to immigrants.
Meanwhile, we ignore the real “waste, fraud and abuse” in the system by the tens of billions overcharged by Medicare Advantage plans or the private equity schemes that bankrupted Crozer Chester and Taylor hospitals or Hahnemann.
The “big, beautiful bill” was supposed to cover only the original intent of the Medicare and Medicaid program. Instead, it will destroy the fragile infrastructure of healthcare.
Maybe we need a new guiding principle on this anniversary: Healthcare is a public good, not a market commodity, and we should finally get that big salami.
Dr. Walter Tsou is a former health commissioner of Philadelphia and a national board adviser to Physicians for a National Health Program.
