Anniversary Narratives of the Health Care State: Institutional Entrenchment in Retrospect

Abstract

Institutional narratives, appealing both to the intellect and the imagination, are powerful mechanisms of entrenchment. Drawing on close examination of legislative debates, interview transcripts, and official documents, this article analyzes institutional narratives of the British National Health Service (NHS) and American Medicare and Medicaid. These narratives take the form of epics, featuring founding heroes, adversaries, stewards, saviors, and other characters, and are retold on multiple occasions, and especially on anniversaries of the founding date. In the process, certain elements of history are remembered, and others forgotten. The myth of the NHS as a single national institution obscured much of the complexity and compromise that went into its founding and subsequent development, but preserved fidelity to its founding principles. In the United States, the dominant narrative belonged to Medicare, while Medicaid featured as an afterthought. In the case of the NHS, narrative entrenchment served to preserve universal access to comprehensive health care. In the case of American Medicare, entrenchment preserved the original mission of the institution but kept it from expanding to a broader swath of the population, even as its less-entrenched companion Medicaid provided a vehicle for coverage of an increasingly wide range of population groups. A distinct Medicaid narrative developed only after incremental expansion was well underway.

The “health care state” is one of the integral institutional features of modern political systems. Defined by Michael Moran (1999: 15) as the “interpenetration of the institutions of the healthcare system and the institutions of the state,” the health care state is a set of institutions for the governance, finance, and delivery of health care that has pervasive implications for the experience of citizenship, the functioning of the economy, and the general well-being of society. It is in that sense a “constitutive” feature of advanced liberal democracies. As such, it is both the site and the object of political contestation.

Health care states may be more or less resistant to change through such contests—that is, more or less “entrenched.” As conceived by Paul Starr (2019: 1), entrenched elements of social structure “resist stress . . . defy pressure . . . overcome opposition.” Mechanisms of entrenchment are varied. Some operate through the “rational choice” of actors as a matter of strategic design or in response to processes of increasing returns or “information cascades” (12–16). Other mechanisms are grounded in cultural processes in which beliefs become “embedded” and institutions “deepen” their societal roots (21–26). One of these cultural mechanisms is the development of institutional narratives.

In the institutional context, narratives constitute the core discourse through which the understanding of purpose within institutions is developed, conveyed, and internalized by members of the institution over time. Narratives have plots that trace the pursuit of purpose from the establishment of the institution through to the present and into the future. They establish “paradigmatic” roles of institutional membership (Linde 2009: chap. 7), and they record in institutional memory how different characters have performed these roles over time. But they are also “silent” on other aspects of institutional experience (chap. 9). These narratives play a powerful role in entrenching certain aspects of the institutional mission and ignoring others; as anthropologist Mary Douglas (1986: 69) once noted, “institutions remember and forget.”

Narratives are key to maintaining the integrity of an institution (Kirby 2021)—namely, the institution's fidelity to the purpose or mission for which it was established, and the related ethic of behavior that animates those who serve that purpose. Institutional integrity differs from the formal logic of the institution—that is, the set of “collectively enforced expectations” that governs the behavior of institutional actors “regardless of what they would want to do on their own,” and that are sufficiently formalized that they can be enforced by third parties (Streeck and Thelen 2005: 9, 10). Institutional integrity, in contrast, is maintained by an internalized ethic of behavior that is formed within the institution (Heclo 2008) and by a sense of institutional mission or purpose within its members. These morally inflected understandings may persist even through changes in formal institutional logic. They may allow the institution not only to survive frontal attacks but also to resist gradual transformation through such processes as layering, drift, and conversion in which fundamental change is “masked by stability on the surface” while the original purpose is gradually abandoned or supplanted (Streeck and Thelen 2005: 22–26).

The study of institutional narratives can, at the very least, flesh out our understanding of the political dynamics of change in the welfare state. More ambitiously, it can unlock puzzles that other approaches struggle to explain. In this article, I show how a narrative focus can help to explain a puzzle in the American health care state with which various observers have wrestled: the “divergent political evolutions of the Medicaid and Medicare programs” (Brown and Sparer 2003: 31) that saw the popular Medicare program prove highly resistant to the expansion of its beneficiary base beyond the elderly and disabled, whereas Medicaid, initially stigmatized as a “poor people's program,” could be incrementally expanded and ultimately reframed as a middle-class entitlement (Grogan and Patashnik 2003). A comparison with the British National Health Service (NHS), which retained its integrity through multiple episodes of reforms to its formal logic, provides a benchmark against which to assess the elements and effects of institutional narratives in the American cases.

Identifying Institutional Narratives: Concepts and Methods

In exploring these dynamics we can build on a set of conceptual and analytic tools associated with the narrative policy framework (NPF) (Shanahan et al. 2017). The foundational insight of the NPF was that because policy narratives are structured by the essential elements of the narrative form—setting, plot, character, and moral—those common elements can be used empirically to identify policy narratives and to compare them across cases and relate them to other variables. The elements also characterize institutional narratives, as follows:

• a. Plot: The plot of an institutional narrative unfolds over time: it relates to the past, the present, and the future. It has a “narrative logic,” a sequence of events or actions in which one thing leads to another in a particular place and time. It explains and gives meaning to the course of institutional evolution.

• b. Character: Characters in institutional narratives are recognizable figures, who may be individuals or more composite figures such as “citizens” or “members,” who have motives and desires and who make choices and take actions that drive the plot. These characters perform identifiable roles such as “heroes” who advance the mission of the institution in extraordinary ways, “villains” who would thwart the mission, and “stewards” or “rescuers” who would preserve or save it.¹

• c. Setting: The plot of an institutional narrative unfolds in a particular setting, which locates the institution in a specific time and place and relates it to other elements of society within that context.

• d. Moral: The moral gives normative weight to the social purpose served by the institution and to the actions of characters serving that purpose. Essentially, the moral presents the institutional purpose as a “mission.”²

Two of these elements—plot and character—are essential to the identification of institutional narratives.³ To depict the life of a social entity that exists over some period of time, an institutional narrative must have a temporal plot tracing a past-present-future arc and driven by the actions and choices of human characters. To identify institutional narratives in the American and British health care states, I therefore look for discourse that has these features. In each case I also note the settings that flesh out the plot and the moral that derives from it. Some of these narratives are fuller and more vivid than others; they differ, for example, in the detail in which they evoke settings and/or characters in institutional history, and in their relative attention to the past, the present, and the future. But all exhibit the past-present-future story arc and the actions and motives of recognizable characters.

I focus on those moments at which the telling and retelling of the institutional narrative is most apparent and most deliberate: namely, the anniversary dates of the “founding.” In the American case this means the establishment of Medicare and Medicaid with the signing of Title XVIII and Title XIX of the Social Security Act in 1965. In the British case, it is the effective date of the legislation establishing the NHS in 1948.

I also focus on venues that are amenable to a narrative format: public documents issued by the institutions themselves, reported interviews with actors in the institutional leadership, and records of legislative debates. Additional material is available in an online appendix (hereinafter OA).

The Distinctive Power of Institutional Narratives

The power of narrative in institutional life derives from its unique ability to appeal to both the intellect and the imagination. While lacking the replicability of systematic enquiry, an institutional narrative offers a “reason-structured” (Misak 2008) explanation of the history of the institution through the motives and actions of particular characters as they respond to events in a particular time and place. By inviting the audience into the worlds of those characters, the narrative also calls for an imaginative leap. Narratives thus combine “two traditional strands in the history of rhetoric: the argumentative, persuasive theme and the literary, aesthetic theme” (Fisher 1984: 2).

Because they extend over the full life span of the institution and involve the pursuit of broad collective goals, institutional narratives can be seen as a particular type of narrative, namely as “epics,” and indeed as “heroic epics.”⁴ An epic is a “grand narrative” whose plot depicts a “single large action” (Turner 2012: 432),⁵ a fateful choice with large consequences. The characters are idealized individuals (most centrally the hero) or composite representations of categories of individuals (such as “patriots”) of extraordinary virtue (or vice). The setting sweeps across time. The moral is constitutive of a normative order, serving to justify or condemn present behavior. Classically, the epic “relates in an elevated style the adventures of a heroic figure through whom a nation's identity is defined, or fate decided” (Keen 2015: 21). Classical epics were reperformed and reshaped over time, sometimes in narrative competitions, in an ongoing process of cultural affirmation. We can think of contemporary institutional anniversary narratives in similar terms.

Central to any institutional narrative is the “single large action” of the founding moment: the historical point at which the institution is established, typically by a visionary and valorous founder or set of founders and often against opposition, to address an unmet need. In this narrative the prefounding period must be shown to be deficient in some important way. The founding moment sets a new course, and what happens then contains the seeds of future developments. This depiction embodies central “truths” about how the institution is conceived and experienced, but it thereby also magnifies certain features while downplaying others. (Institutional narratives are thus stylized accounts and different from comprehensive third-party histories, although those histories too may be selective. Actors and events that figure in the institution's history may not have a role in the narrative plot and may therefore appear fleetingly if at all.) At each anniversary this narrative is retold, and the present is assessed in terms of its fidelity to the founding vision. And with each retelling, some aspects of the past are remembered, and others forgotten.

In both Britain and America, the principal characters in the founding narratives of the health care state are the founding heroes, their opponents, and the everyday folk who were rescued from need. Like the heroes of epics ranging from the ancient Greeks (Nagy 2013) to the nationalist myths of more recent centuries (Geary 2002), the heroes made critical choices and persevered against opponents of their cause for the benefit of everyday folk, thereby setting the course of events that would be remembered and celebrated by subsequent generations. As the institutional narrative was retold over time, other characters such as stewards, saviors, betrayers, worthy and unworthy beneficiaries, and “everyday heroes” were introduced and portrayed in terms of their fidelity or infidelity to the founding vision.

These narratives took hold in two institutional realms: the political/ representative (the executive and legislative) and the administrative (the relevant health departments and agencies). These parallel versions complemented each other in that political developments figured within the administrative narrative and vice versa. Notably, in the UK the political world was depicted within the administrative narrative as a source of potential disruption; in the United States political contestation was portrayed as a way of life.

Britain

The Founding

The institutional narrative of the NHS (though not the longer history that led to its establishment) begins with William Beveridge, the Liberal author of the landmark 1942 report (technically, the report of the Interministerial Committee on Social Insurance and Allied Services) that sketched the architecture of a national health service. Written in the depths of wartime, the Beveridge report traced a plot that looked ahead to victory and a grand postwar reconstruction project (OA #1). The villains to be vanquished would no longer be wartime enemies but rather the “five giant evils” of “want, disease, ignorance, squalor, and idleness” (Beveridge 1942: 6). The principal characters in this narrative were a disembodied but benevolent state and a paradigmatic resourceful and responsible citizen—a depiction consistent with Beveridge's earlier thinking about welfare economics (Komine 2010: 208).

After several abortive attempts by the wartime coalition government and its Conservative successor under Prime Minister Winston Churchill to develop a compromise design, the task of converting Beveridge's outline into legislation fell to Aneurin (Nye) Bevan, the charismatic health secretary in the postwar Labor government that swept into office in 1945 “wrapped . . . in the pages of the Beveridge report” (Fielding 1992: 633–34). Bevan enters the narrative as the second founding hero. He depicted the health secretary as a sort of servant hero in a plot in which citizens and health workers who had previously suffered in silence would be empowered. The secretary would be a “whipping-boy for the Health Service in Parliament . . . [and] a shock-absorber between Parliament on one side and the vast body of health workers on the other” (OA #2). The NHS would not be a “bureaucracy” but rather a new social institution, a sort of workers' cooperative in which “health workers in every field [are] organized and represented on the various bodies” (BMJ1948: 612; fuller quote in OA #3).

This depiction was consistent with the institutional logic of the NHS. Through a series of foundational compromises the NHS was established as a regionalized and quasi-corporatist⁶ hierarchy with three initial pillars: nationally owned hospitals employing specialists,⁷ contracted general practitioners, and locally run public and community health services. Within that formal structure, local networks of providers effectively determined the allocation of resources (both formally and informally) within centrally established budgets, while public health, the historical purview of local authorities, coexisted uneasily within the new regime. The internal tensions within the model—between centralization and decentralization and between clinicians and managers—would never be resolved. Those tensions would drive an ongoing pattern of policy cycling and would condition attempts at more sweeping reforms over the ensuing decades (Tuohy 2018a).

The complexity of those compromises and tensions, however, was “forgotten” in the presentation of the NHS as a national institution accountable to citizens through the secretary of state and Parliament, in which all citizens have equal rights and responsibilities, replacing an earlier regime of unequal and inadequate care. Colourful Bevan quotes about how kicked-over “buckets of slops” or “dropped bedpans” would set up a “wail in Whitehall” or “echo in the halls of Westminster” would be continually invoked over the years. Even as this centralizing narrative implied a degree of coherence and central control that Bevan never intended (Timmins 2018: 13), it conveyed the core mission of the NHS: to provide access to health care to all citizens “free at the point of service” and to “universalize the best” in quality of care. Fidelity to this vision would condition all later reform attempts.

Anniversary Narratives

The anniversary retellings of the NHS narrative, in both parliamentary and administrative venues, consistently re-created its birth in a postwar setting, lionized the founding heroes, traced a plot in which the institution was in recurrent peril, demanded stewardship or rescue to pass it on to future generations, and presented these responsibilities as a moral imperative. The principal roles are those of the founders, the governmental stewards, and the everyday heroes who uphold the legacy through unstinting health care service. From the time of Beveridge's five giant evils, the villains in this narrative are more likely to be depicted in impersonal terms as broad phenomena—e.g., demographic change or obesity—than as identifiable human beings (apart from a few instances of partisan sniping).

Powell (2019) has analyzed the NHS narratives told in parliamentary debates at each decennial anniversary from 1958 to 2008. He finds that each debate revisited the “creation” narrative from different partisan perspectives, with each party competing to emphasize the roles of their copartisan heroes. Bevan was the clear Labor hero, while Conservatives struggled to insert Churchill and his health minister, Henry Willink, into the tale. Beveridge was invoked less often, although in the 1988 debate a Liberal member noted “the well-known liberal, William Beveridge, who first conceived the idea of an NHS” (9). In a departure from this norm in the 2008 debate, Andrew Lansley, the Conservative shadow health secretary, attempted an overarching if deceptive cross-party view of the founding, asking that the debate be conducted “entirely in the spirit in which the NHS was created . . . inspired by the work of a Liberal, William Beveridge, designed by a Conservative, Henry Willink, and implemented by a socialist, Aneurin Bevan” (13).

In a narrative plot that became more prominent over time, Labor MPs villainized the Conservatives as having voted against the NHS Act at each legislative stage, while Conservatives maintained that their forebears had been conscientious objectors to means, not ends (14–15). As time passed a new collective character, the responsible steward of the legacy, appeared. Each party competed for that mantle while casting the other as a betrayer. At each debate, the NHS was portrayed as being in peril, and each party presented itself as the real or potential savior. Meanwhile, problems facing the NHS were identified with recurrent regularity: “finance, demography, technology, waiting lists, staff shortages, staff morale, reorganisation and the ‘Beveridge fallacy’ of assuming that demand for healthcare would fall [as access to care rendered the population healthier]” (15).

The parliamentary debate at the most recent decennial anniversary in 2018 can further illustrate this dynamic. The debate opened with a tribute to Nye Bevan by the current Labor incumbent of Bevan's Welsh seat (OA #4). Even a Scottish Conservative rose to “commend the Labour Government who, 70 years ago, in the dark days of a post-war Britain, had the courage and foresight to create the national health service,” while also invoking the stewardship narrative of “successive Governments, including, dare I say, Conservative Governments, who have supported the service that we all continue to value so much?” True to form, however, this tribute was quickly amended by a Conservative colleague who wished to remind the House that “in January 1944, Henry Willink, a Conservative Minister in the coalition Government, held up the first White Paper that said, ‘national health service’” (UK Parliament 2018: cols. 134WH–35WH).

In all, 14 members spoke (8 Labor, 4 Conservative, 1 Scottish National Party, and 1 Liberal Democrat) and presented a common narrative in which the NHS had risen from its founding by visionaries in the throes of postwar reconstruction to become one of the nation's proudest collective achievements. Six MPs spoke of the NHS as a matter of national pride, and six portrayed its noble mission, including a member of the Scottish National Party (not typically given to celebrating UK-wide institutions) (OA #5).

The principal roles in this narrative plot were those of the founders, the stewards and defenders of the legacy, and the “everyday heroes” (NHS staff). Six speakers referenced the founders, nine portrayed the stewardship of their respective parties over time, and seven paid tribute to NHS staff. As in previous debates, threats to the NHS were presented as challenges to be overcome by the current generation of NHS stewards and defenders, and in this case the principal emphasis was on obesity and the related prevalence of diabetes. Although as noted there was some partisan contesting over the identity of the characters in these roles, especially those of founders and stewards, the narratives told by members of different parties were generally concordant.

Powell (2018) has also explored the narrative dimensions of “anniversary documents” associated with the governments of the day. He reviewed seven policy documents produced by the secretary of state for health either directly or by commissioning an arm's-length inquiry, and issued close in time to a decennial anniversary of the institution. Each of these documents bar one was produced in response to a perceived “crisis” facing the NHS. Accordingly, they share a common plot in which the founding principles constitute a legacy that is under threat and must be defended by the current generation of stewards by reinventing or “saving” the NHS. The particular nature of the perils and rescues identified in each report showed a cyclic pattern, ebbing and flowing with enthusiasms in the broader world of public policy (578–80).

Meanwhile, parallel versions of the narrative of a revered institution preserved through time despite near-constant peril developed within the administrative pillar, as evident in documents produced by the NHS itself. For purposes of this brief overview, three such documents produced in the last two decades, each drafted through an intensive consultative process within the NHS, can serve to illustrate.⁸ One, the “Next Stage Review” of the NHS, was published in 2008 on the occasion of the 60th anniversary. It was conducted under the aegis of the Labor government by a leading academic surgeon, Lord Ara Darzi, and signed by the clinical leads of each of the 10 Strategic Health Authorities in England. It began with an invocation of the founding, paying “tribute to a service founded in adversity, from which were established enduring principles of equal access for all based on need and not ability to pay” (Department of Health 2008: 7). It depicted the “journey” of improvement made possible by historic levels of increased investment in the NHS over the previous decade and “delivered by the dedication and hard work of NHS staff,” illustrated with anecdotes from Darzi's own practice. Its recommendations were presented as the “next stage” of that journey, which would “move from an NHS that has rightly focused on increasing the quantity of care to one that focuses on improving the quality of care” (7–8). But it also recorded the “change fatigue” among NHS staff after nearly two decades of continual organization change, as a series of “market-oriented” reforms had been rolled out under successive Conservative and Labor governments (13). Only two years later, however, a newly elected Conservative/Liberal-Democrat coalition government embarked on a more sweeping reorganization of the NHS than had occurred for 20 years.

Dissatisfaction with that reorganization soon drove yet another more gradual round of organizational change, reintegrating the purchaser and provider sides. A “Five Year Forward View” planning document was produced in 2014 by the new NHS chief executive, Simon Stevens, developed through a process of intensive internal consultation and widely endorsed within the NHS. Incremental changes were captured, consolidated, and further spurred by an “NHS Long-Term Plan” released in January 2019, acknowledging the 70th anniversary year just ended and invoking the spirit of universalizing the best that had animated Bevan (NHS England 2019: 114–15). A new Health and Care Act codifying those changes was enacted in April 2022.

The “Five Year Forward View” and the “NHS Long-Term Plan” effectively form a two-part set, emanating from within the NHS as consensus documents. Together they depict a legacy from the founders, a history of stewardship, a present peril, and a scenario of renewal. They emphasized enduring national pride in the NHS and the “shared social commitment it represents,” the changed circumstances of the present (with challenges of funding, staffing, health inequalities, and population aging), and optimism that current and future generations would rise to those challenges (OA #6, 7).

Institutional Logics and Institutional Integrity

The ubiquity and consistency of this narrative gave the NHS a remarkable resilience through multiple reform attempts. For the first 40 years, the NHS moved through cycles of centralization versus decentralization, autonomy versus integration, and professionalism versus managerialism within the overall logic of the quasi-corporatist hierarchy (Tuohy 2018a: 92–98). Beginning in 1990, successive governments embarked on a series of major market-oriented reforms that shifted the logic toward one of contracting among formally independent “commissioners” and public and private “providers” under the purview of an ever-changing array of central regulators.

The 2012 reforms under the Conservative/Liberal-Democrat coalition government attempted to go further by providing for indirect rather than direct control of the NHS by the secretary of state. That measure was seen as threatening the institutional integrity of the NHS as a single national institution accountable through the secretary. Furious opposition triggered both an unprecedented “pause” in the legislative process for additional consultation and a set of amendments in the House of Lords, effectively reinstating the secretary's traditional role (312–16).

This continual series of reform attempts was portrayed within the institutional narrative as disruptive churn or “redisorganization” originating in the external political environment and imposed by politicians with no lived experience of the organization. The myth of the single national institution—which forgets the NHS's birth in compromise between clinicians and managers and between central and local authorities—provides no narrative frame in which ongoing renegotiation of those compromises could be seen as part of the legacy's unfolding.

Accordingly, the institutional response to these reforms was marked by attempts to work within and around legislative constraints to maintain more familiar, closely integrated working relationships. Among other things, commissioners did not fully exploit their capacity to contract with private clinics, which accounted for less than 10% of total spending throughout the period of the Labor, Coalition, and Conservative governments (Tuohy 2018a: 456–66; Kings Fund 2021). The 2022 Health and Care Act effectively formalized these informal workarounds, reintegrating purchasers and providers into new locally based partnerships known as Integrated Care Systems, consolidating central regulatory functions within the NHS, and strengthening the powers of the secretary of state for health. These reforms would return the NHS to something approximating its pre-1990 logic, although the three-decade-long experiment with market-based reforms left its deposit in the form of strengthened and more sophisticated commissioning capacity at the local level, greater clinician (and especially general practitioner) involvement, greater specificity in commissioning, and greater managerial discretion for providers. True to the founding narrative, the institutional integrity of the NHS as a single institution accountable to Parliament for the provision of comprehensive health care free at the point of delivery was preserved throughout these changes. Public health expenditure as a proportion of total health expenditure stayed remarkably consistent at about 84% during the 1990–2020 period.

The United States

The Founding

As in Britain, the founding myth of the American health care state depicts persistent heroes who made momentous choices in the face of adversity to expand public health care coverage. Unlike the British case, however, the adversaries were not disembodied evils but rather partisan opponents and the powerful interests who allied with them. From the beginning, a partisan division was built into the story. Nor did the founding myth draw on a grand national cultural epic of rising to an historic challenge such as postwar reconstruction. President Harry Truman attempted to do so in the immediate postwar period, situating universal national health insurance within the emerging postwar discourse of universal rights, and proposing an “Economic Bill of Rights” to include “health security for all, regardless of residence, station, or race—everywhere in the United States” (Truman 1945). But Truman's attempt to introduce a program of universal health insurance foundered on divisions within the Democratic Party. The founding narrative of the American health care state began in the setting of that political acrimony. The plot begins with Truman's heroic failure, with Truman cast as the iconic hero of the lost cause who “believed in the reform, stated it clearly, and clung to it doggedly” (Blumenthal and Morone 2010: 58). What followed over ensuing decades were partisan narratives of universal health care as the object of a struggle and a fight. For Democrats, this was a narrative of unfinished business; for Republicans it was about resistance to creeping socialism.

The pillars of the American health care state—Medicare and Medicaid—were established in 1965 in that context. Indeed, President Lyndon Johnson chose to sign the founding legislation in Independence, Missouri, former President Truman's home town, in the presence of Truman himself. In his signing speech Johnson paid eloquent tribute to Tru-man and also called the “honor roll” of the heroes who had “led us to this historic day,” including 14 other current and former Democratic members of Congress and the administration, and President John F. Kennedy (Johnson 1965). The principal focus of his address, constituting more than half of the 2,550-word text, was the long struggle for passage of national health insurance. This essentially partisan narrative of struggle against opposing forces was to persist as an ongoing theme of discourse in the decades ahead.

The plot of the Medicare narrative depicted the program not in Beveridge's revolutionary terms but as an heroic accomplishment along a road of continuity, building on the foundations of the American welfare state and the private insurance industry. The characters were not only the program's founding heroes but also the responsible and industrious folk who would be rescued from the perils of illness and financial hardship in old age by being enabled to provide for themselves through Social Security. This depiction was apparent in President Kennedy's major speech on May 20, 1962, at a rally in Madison Square Garden in New York City (OA #8, 9), and Johnson continued the theme. In his signing speech Johnson characterized the legislation as ensuring that “every citizen will be able, in his productive years when he is earning, to insure himself against the ravages of illness in his old age.” The Judeo-Christian “hand of justice” was extended not to all but “to those who have given a lifetime of service and wisdom and labor to the progress of this progressive country”—that is, to the elderly (OA #10). The moral of the story was that of a cross-generational social compact.

Even if the setting and plot of this founding narrative were essentially partisan, the sympathetic characters of the beneficiaries and the moral of a cross-generational compact allowed the story to be told from different partisan perspectives—either as a landmark in an ongoing quest for universal coverage or as the culmination of a project begun with Social Security. From the Democratic perspective, heroic founders, in establishing coverage for the elderly against the opposition of powerful interests, had won an important battle but not the war in an unfinished crusade for universal health insurance. In the Republican perspective, vigilant defenders of freedom continued to guard against further “socialist” expansion. And within the broad consensus that marked the first three decades of Medicare's existence (Oberlander 2003: 4–7), these two perspectives could cohabit, albeit in tension. With the fracturing of that consensus in the 1990s, the perspectives would sharply diverge.

Medicaid, on the other hand, added at the last minute for reasons purely of political strategy as part of a grand pragmatic compromise, lacked a coherent founding narrative. It provided federal support for state-based programs of cash assistance largely targeted at poor, single-headed families with children but with varying eligibility requirements, as part of a “three-layer cake” design tacked onto Medicare Part A (hospital insurance funded from general revenues) and Medicare Part B (physician services insurance funded through voluntary contributions to a trust fund). Medicaid played essentially no role in this founding discourse. Johnson made no mention of it in his signing speech, which related entirely to “this Medicare bill” and the population it would cover. Smith notes that “[w]hen initially passed, the Medicaid title was a much less finished statutory product than Medicare” (Smith 2002: 25). Observers saw it as suffering from “a lack of clarity about what Medicaid was and for whom it was created” (Stevens and Stevens 1974: 349) and “an identity crisis aggravated—or perhaps blessed, depending on one's point of view—by an ambiguity over its intended primary clientele” (Shaw 2009–10: 649).

Anniversary Narratives

The depiction of the founding moment as the sealing of a cross-generational social compact would become central to the institutional narrative of Medicare, and it took root within both the political/representative pillar and the administrative pillar. But the two opposing partisan perspectives lived in constant tension, especially as partisan divisions deepened in the 1990s. Medicaid, lacking a coherent institutional narrative, essentially rode in Medicare's narrative wake and was otherwise narratively “forgotten.”

Also overshadowed, if not forgotten, was Medicare's role in covering the disabled. The one expansion of Medicare eligibility took place with the Social Security Amendments of 1972, extending Medicare eligibility under a new Supplemental Security Income program for the low-income elderly and disabled, effectively federalizing coverage for those previously reliant on state-based social assistance as well as those with end-stage renal disease (Smith 2002: 25–26). But if the administrative designers of Medicare coverage saw this as a “natural, almost automatic step” (Oberlander 2003: 40–41), it was not part of the cross-generational compact narrative of the “founding moment” of 1965. Subsequently the disabled would appear in the narrative only when coupled with the elderly under the uneasy yoke of the founding compact.⁹

Of the five presidents in office on the decennial anniversary dates of the passage of the legislation, only the two Democrats (Clinton and Obama) issued statements to mark the occasion. Each was in office in a time of fierce partisan rivalry. Each portrayed his own agenda as the next phase of stewardship of the legacy of an epic national achievement, against opposition such as that faced by the founders. Clinton used the occasion of the 30th anniversary in 1995 to portray himself within “the tradition of the Presidents who fought for Medicare” (Theodore Roosevelt, Truman, Kennedy, and Johnson) and to lay the defeat of his own attempt at health care reform at the feet of the recurring villains, “the same crowd that killed Harry Truman's plan for healthcare, the same crowd that fought against Medicare” (Clinton 1995). In the current time of peril, “we need to celebrate and recommit ourselves” to the “social compact of the American family” of which Medicare is part. Except for one paragraph devoted to Medicaid, the speech focused almost entirely on Medicare.

Similarly, Obama issued a presidential proclamation to mark the 50th anniversary of Medicare and Medicaid in 2015, and he used the occasion to defend his own health care reform as a chapter of an ongoing national crusade. In this case, however, given the key role Medicaid expansion played in that reform, Medicaid received equal billing in the anniversary message—not with its own identity, however, but as part of a “Medicare and Medicaid” package (OA #11).

In Congress, each decennial anniversary was recognized. I focus here on debates in the Senate, where rules allow speakers greater scope. Table 1 shows the number of addresses devoted to the anniversary and those that qualify as “narratives” tracing a past-present-future arc driven by the choices of characters. (Representative textual examples are given in OA#12–16.) Medicare dramatically dominates in the early decades, both in overall attention and in narrative presentation. It is not until the 21st century that Medicaid receives equal or greater treatment.

Of the 41 anniversary addresses, only 5 were offered by Republicans, 1 at each anniversary. In 1975 Republican Paul Fannin, the only speaker in the perfunctory recognition of the 10th anniversary, drew attention to the escalating costs of Medicare and entered into the record a Washington Post article by Stuart Auerbach as evidence that “dramatizes the dilemma between costs and regulation and therefore should be thoroughly studied” (US Congress 1975: 25628). Fannin's nonnarrative argument ignored the narrative arc of Auerbach's article, which moved from past controversy to present partisan “neutrality” to a future in which Medicare could “[point] the way to a workable national health insurance program.” Republicans Pete Domenici in 1995 and Orrin Hatch in 2015 offered dystopic narratives in which programs conceived in the past were in crisis in the present and would not celebrate future anniversaries, to the betrayal of coming generations. They cast Republicans as the current would-be saviors fulfilling a moral responsibility for reform against Democratic intransigence. Robert Dole¹⁰ in 1985 and Bill Frist in 2005 offered more positive accounts that evoked the signing, praised Johnson, celebrated the contributions of the current Republican administration to Medicare reform, and looked toward the continuance of reforms to maintain the “compact between generations” and the commitment to future beneficiaries.

Of the 36 Democratic addresses, 30 were in narrative form. Themes were remarkably consistent across speakers and time. Twenty-four evoked Johnson's signing of the legislation, sometimes with cinematic attention to the scene in Independence and often with reference to Truman and other Democratic heroes, and seven situated the event as the culmination of a long struggle against constant attack. Fifteen portrayed a present contest between Democratic defenders and Republican attackers, especially given that all anniversary debates except the 10th occurred in the setting of Republican control of the Senate. Thirteen projected this need for defense into the future, and six explicitly looked forward to the celebration of future anniversaries. Twenty-six called for fidelity to the founding purpose, variously portrayed as a social compact between generations (sixteen) and an embodiment of American values of mutual obligation and protection of the vulnerable (six).

For the first three decades, these anniversary addresses were entirely or predominantly about Medicare. Medicaid appears in the “single large action” of the founding moment only when twinned with Medicare, and Medicaid beneficiaries appear in a composite group of “the elderly, the disabled, and the poor.” The sole exception is a 1985 address by Ted Kennedy, who still twinned the programs while also offering a brief separate description of Medicaid as having “become a healthcare bill of rights for poor Americans,” rescuing them from “unnecessary suffering . . . and. . . . lost hope” in the American promise of equality and compassion (US Congress 1985: 21362).

But in the 2000s, a separate Medicaid narrative begins to appear (OA #14–16). It is not an epic—it has no “single large action”—but rather it depicts the incremental growth of the program to cover a much broader swath of the population, a history described in more detail below. This narrative is crystallized in a concurrent resolution cosponsored by all Democratic senators (and no Republicans) on the 40th anniversary in 2005, which recognized Medicaid as “a core component of the American health system . . . providing health and long-term care for more than 58 million Americans, including children, pregnant women, individuals with disabilities, and the elderly who are poor and frail” (US Congress 2005: S9542). The result, however, is a somewhat tangled tale in which Medicaid is alternately described either as being true to or transformed from its original purpose or mission. In speaking to the resolution, Jon Corzine traced the growth of Medicaid “from a safety net program to the primary source of care for millions of Americans” (S9543). Jay Rockefeller, on the other hand, depicted a different sort of evolution, from the establishment of Medicaid as a “social contract with our fellow Americans” and “a reflection of a [‘characteristically American'] tradition of community and mutual obligation” to having become “a scapegoat for the larger ills facing our entire healthcare system” (S9546).

This lack of clarity may underlie a surprising “forgetfulness” within the emerging Medicaid narrative: namely, the scant attention paid to the program's impact on improving health equity across racial and ethnic groups despite the disproportionate representation of those groups among Medicaid beneficiaries (Guth and Artiga 2022). Indeed, the narrative of expansion across the population may reinforce this silence. Apart from one mention in the preamble to the 2005 Medicaid resolution,¹¹ no Senate address highlights this feature of the program.

The 50th anniversary in 2015 featured Medicaid yet more prominently, given the key role the program had played in the extension of coverage under the Affordable Care Act. Eight senators spoke, all but one of whom were Democrats. As in Obama's 50th anniversary proclamation, Medicaid had roughly equal weight with Medicare. The dominant plot was that of an enduring and relentless partisan battle, now incorporating the Affordable Care Act as well. Senator Patrick Leahy provided the fullest treatment of the story arc from Truman to Obama and beyond, casting the current generation as stewards of the legacy, portraying the Affordable Care Act as the present “step further,” and committing to “fight for these programs for my children and my grandchildren” (OA #16). Minority Leader Harry Reid likened Republicans' opposition to the passage of Medicare as “socialized medicine” to their current attacks on the Affordable Care Act, and he extended the story into a future in which “[w]e will be celebrating ObamaCare's success 50 years from now while Republicans call for the Affordable Care Act to be phased out, like Jeb Bush wants” (US Congress 2015: S6148). Though most spoke of the current generation's responsibility to protect and preserve the two programs, two Democratic senators offered narratives of continual evolution and projected innovations that each program would lead. The one Republican speaker, Orrin Hatch, made no reference to Johnson or the founding but depicted the present as one in which both programs faced unsustainable fiscal challenges and Medicaid was “probably the worst health insurance in the country.” Calling for a bipartisan effort to avert the dystopian future of the “coming entitlement crisis before it is too late,” Hatch extended the cross-generational compact to the future. Invoking his 23 grandchildren and 16 great-grandchildren, he concluded: “On this landmark anniversary of the Medicare Program, I urge my colleagues to also consider future generations of Americans and the costs and burdens we will pass on to them if we fail in this endeavor” (US Congress 2015: S6167).

Unlike the UK, where the political environment was viewed as an external source of disruption, political contestation in the United States extended to the administrative pillar as well, as a way of life for the institution. A set of interviews with previous administrators and acting administrators of Medicare and Medicaid, conducted on the occasion of the 50th anniversary of the programs, offers windows into that world (NASI 2016). Although successive administrators generally identified as members of a “club” of shared experience that transcended their political affiliations (for example, they periodically gathered for dinner), they also saw their roles as having to constantly navigate the partisan divide (OA #17, 18).

In a second plot line, the early incrementalism and pragmatism became not just a necessity but also a mission. Initially conceived by its administrative architects as offering a politically feasible proof of concept that would ease its extension to other population groups,¹² Medicare (and to a lesser extent Medicaid) offered a home to institutional pioneers. On the 30th anniversary of the legislation's passage, Robert Ball, a senior administrator in the Bureau of Old-Age, Survivors, and Disability Insurance within the Social Security Administration from 1952 to 1962 and then commissioner of Social Security from 1962 to 1973, reflected on the conception and unfolding of this strategy. Ball (1995: 62–63, 70; fuller quote in OA #19) noted how, just as leading advocates within the administration and the labor movement “saw insurance for the elderly as . . . a first step toward universal national health insurance,” their successors had developed Medicare into “a leader in the health insurance field,” modeling new approaches to payment and quality assurance that could be emulated across the sector.¹³ Wilbur Cohen, who served in the Department of Health, Education and Welfare as assistant secretary in the Kennedy administration and as undersecretary and then secretary under Johnson, similarly favored an incremental approach, although less as a matter of political strategy than of administrative pragmatism (OA #20).¹⁴

This ethos, which was also expressed in the granting of waivers for state governments to experiment with new approaches in the Medicaid program,¹⁵ culminated in the establishment of the Center for Medicare and Medicaid Innovation (CMMI) under the Affordable Care Act of 2010. As described by one Centers for Medicare and Medicaid Services (CMS) administrator, CMMI presents an opportunity to “shape the healthcare enterprise toward real health and well-being as well as excellence and proper frugality, stewardship of resources, better care, better health, lower costs” (Don Berwick, quoted in NASI 2016: 33; fuller quote in OA #21). More formally, an official statement from CMS marking the 50th anniversary echoed this theme. Beginning by acknowledging Johnson's signing of the legislation in 1965 as a moment when “the landscape of healthcare in America changed forever,” the statement goes on to place “driving innovation” on par with “changing lives” and “increasing access” as the signal accomplishments of Medicare and Medicaid (CMS 2015; OA #22). The innovation narrative, moreover, has been embraced by administrators in Republican as well as Democratic administrations, thus showing some potential to bridge the partisan divide (OA #23).

A third plot line within the administrative pillar casts Medicare as the dominant program and Medicaid as a somewhat unruly stepchild. Medicare is seen as inherently more programmatically coherent, while Medicaid is complicated by its federal–state structure. In 50th anniversary interviews, former administrators of the programs were 60% more likely to refer to Medicare than to Medicaid.¹⁶ The senior/junior statuses of the two programs became part of the story of the establishment of a common institutional umbrella, the Healthcare Financing Administration (HCFA), during the Carter administration. Joseph Califano, former secretary of the Department of Health and Human Services (HHS), saw the move as softening the invidious distinction between Medicare “beneficiaries” and Medicaid “recipients.” Leonard Schaeffer, the HCFA administrator at the time, fit it within the innovation narrative as a chance to “create the largest purchaser of healthcare services in the world and . . . bring healthcare costs down” (quoted in NASI 2016: 291; fuller quote in OA #24). Over time, the general view was that the common administrative umbrella had led to a “struggle of cultures” in a world in which Medicare, as an “organized and stable program,” overshadowed the less coherent Medicaid program, which varies state by state (OA #25). On occasion, a president or secretary who had experience with Medicaid as a state governor could somewhat redress this imbalance, as was the case with Tommy Thompson, secretary of HHS (and former governor of Wisconsin) in the first George W. Bush administration (OA #26).

However, the major change during Thompson's tenure was the reorganization and renaming of the agency responsible for Medicare and Medicaid. The single-administration structure of HCFA had, among other things, fed a Republican narrative of threatening governmental uniformity. By the early 2000s a more disaggregated model was adopted, with separate “centers” for managed care, Medicaid, and Medicare—again for a mix of partisan and administrative purposes, as described by the administrator who oversaw the change (OA #27). The name of the restructured agency was the Centers for Medicare and Medicaid Services. The acronym, however, had a single “M”—CMS. According to Thomas Scully, the then administrator, “CMMS was just too much mumbling, so we came up with CMS. It looked better and sounded better” (NASI 2016: 318). But the phrasing, criticized on the left, symbolized Medicaid's adumbration under Medicare's shadow.

Institutional Logics and Institutional Integrity

Since their founding, the institutional logics of Medicare and Medicaid have shifted through various stages. Partisan and interest-based contests drove considerable changes in institutional logic in both programs, with the increasing introduction of competitive market-type mechanisms and networked managed-care models. But the Medicare-eligible population was expanded only once, in 1972 as discussed above, while Medicaid expanded to cover a progressively broader range of the population.

Medicare began as a single-payer insurance agency, underwriting the reasonable and customary charges of providers without otherwise seeking to organize the delivery of care, and covering something less than half of total health costs for its beneficiaries. Over time, the logic of that model has been pulled in two directions. One was toward a market logic favoring beneficiary choice, as traditional Medicare became one option for publicly funded coverage alongside various plans offered by private insurers, offering at minimum the physician and hospital service benefits in traditional Medicare and paid by Medicare on a capitation basis rather than fee for service. Enrollment in these plans under various program banners (now Medicare Advantage, also known as Part C) fluctuated, but overall it expanded from less than 5% of Medicare enrollment in the mid-1980s to more than 40% in 2021. The second shift, however, was toward an expanded fiscal footprint for the state as program expenditures increased, not only as population aging increased enrollment but also with the extension of benefits (most notably voluntary coverage for prescription drugs, added as Medicare Part D in 2003). The proportion of beneficiaries' total health care expenditures covered by Medicare expanded from 42% in 1968 to 55% in 1997 to 58% in 2014 (PGPF 2021: figure 1; calculations from CMS n.d.). Even as benefits were expanded, however, the definition of the eligible population remained unchanged after 1972. Throughout these shifts in institutional logic, Medicare remained true to its mission and identity as a social security program covering a substantial share of health care costs for the elderly (and the disabled) through a cross-generational compact.

Medicaid, on the other hand, was incrementally extended to more and more population groups, even as state-level initiatives conditioned the benefits in various ways. One major category of incremental expansion resulted from strategic behavior on the part of the nonpoor elderly and disabled: the conversion or transfer of assets to qualify for Medicaid nursing home coverage, which then prompted the introduction of waivers under which states could develop programs of home and community-based services as less costly alternatives to institutional care. By the early 1980s, Medicaid accounted for more than half of all long-term care expenditures in the United States (Doty, Liu, and Weiner 1985: 71, 72, 74). Although this proportion declined to about 43% by 2019 as many states sought to substitute less expensive home and community care for institutional care under federal waivers, Medicaid remained the largest source of funding for long-term care nationwide (Colello 2022: 2).

A second major category of expansion was more deliberate. In 1997, coverage was extended to children in low-income families who were ineligible for Medicaid. Although the program was administered within the federal Medicaid structure, it flew under the banner of the State Children's Health Insurance Program (SCHIP), later simply CHIP, and carried a variety of labels at the state level. Under the Affordable Care Act of 2010, federal funding was provided for states to expand their Medicaid coverage for all people farther up the income scale, and again several did so under a different state-specific brand.

These incremental expansions gave increasing numbers of Americans a stake in Medicaid and contributed to the increased popularity of the program. To some degree support for Medicaid appears to be related to pragmatic perceptions of personal benefit. Those with a direct connection to Medicaid or with an indirect connection through a family member (typically elderly) are generally likely to be more supportive of the program than those without such a connection, although the type of connection matters (Grogan and Park 2017). Similarly, the ACA Medicaid expansion increased support for the program among low-income individuals in states that expanded coverage but not in nonexpansion states (Hopkins and Parish 2019).

Nonetheless Medicare remains the more popular in public sentiment, even though Medicaid is now the larger program by enrollment. In a survey released to mark the 50th anniversary, the Kaiser Family Foundation found substantial support for both programs, but Medicare was more likely to be seen as “very important” (77% vs. 64%) and “working well” (60% vs. 50%) (Norton, DiJulio, and Brodie 2015). There is some evidence that linking proposals for expanded population coverage to either program increases public support for expansion (Sances and Clinton 2021; Karra and Sandoe 2020), although this support is malleable depending on the design and framing of the proposal (Shaw 2009–10; Oberlander 2019).

This returns us to the puzzle presented at the outset: why has Medicaid provided the vehicle for expanding population coverage rather than Medicare? Both programs have been the subject of ongoing partisan contestation, and both have built up dense networks of providers with various interests in expansion or constraint (Smith 2002: 58–59, 78–81). Why was the more popular and iconic Medicare program not gradually expanded to younger population groups, as some of its designers had intended?

Some attempts at explanation point to broad political shifts beginning in the 1970s. Oberlander and Marmor (2015: 65) attribute the disinclination to expand Medicare to “liberalism's political decline, a preoccupation with budget deficits . . . and a turn to market solutions.” Quadagno and Street (2006: 306), on the other hand, argue that is it difficult to discern a coherent philosophy underlying the welfare-state reforms of this period. Expansion of Medicaid to the children of the working poor can be seen either as consistent with the overall rise of the market-oriented agenda of an “enabling state” aimed at propelling beneficiaries into the workforce, or as the expansion of social insurance to incorporate a new beneficiary group into “a public health insurance program, [whose] eligibility rules are considerably more lenient than traditional social assistance” (313). Moreover, this same period saw the enactment of eligibility restrictions on the social-assistance programs to which Medicaid was tied. Brown and Sparer (2003) look instead to American federalism, arguing that by leaving more discretion with the states Medicaid could variously appeal to representatives of both conservative and liberal states. But that same feature allowed states variously to constrict as well as to liberalize eligibility.

Grogan and Patashnik (2003) have argued that incremental expansion allowed Medicaid, presented as a “residual welfare program” until the 1980s, to be reframed in the 1990s as a middle-class entitlement. Grogan and Park (2017) also show that the expansions may have removed or reduced the stigma associated with the program, at least as measured by willingness to enroll in the program if needed. Ironically, however, Grogan and Park (2017) also suggest that the malleability of Medicaid to different frames appears to have generated more confusion than support among beneficiaries and in broader public opinion, given that being connected to the program through a child under variously labeled CHIP programs renders beneficiaries no more politically supportive of Medicaid than the general population. There is some evidence in the present study for the effect of this reframing, in that Medicaid narratives gained traction only in the 2000s, after expansion had occurred. But we are left with the question of why those incremental expansions could occur in Medicaid not Medicare in the first place.

Viewing this phenomenon through a narrative lens suggests a way of filling these explanatory gaps. The institutional narrative of the Medicare program has been told from different partisan perspectives from the time of its founding. A commonly accepted core to these narratives nonetheless portrays the founding as a cross-generational social compact of care for the elderly and disabled through social insurance. The persistence and power of this narrative provide little purchase for adapting the program to a different mission. Democrats and Republicans contest to portray themselves as stewards or saviors of the original vision and to present current perils and future prospects in that light. Conversely, the very lack of a coherent institutional narrative rendered Medicaid a pragmatic vessel for various agendas of expansion. Essentially, Medicaid could be gradually and subtly transformed by “conversion” to different ends, while Medicare retained its institutional integrity.

Drawing Lessons

A strong and coherent institutional narrative is one of the mechanisms by which program entrenchment occurs. The constellation of interests around the program, and the dynamics of positive and negative feedback that it generates, surely matter (Patashnik 2008). But even those who materially benefit or stand to benefit from a program may not necessarily oppose cuts to it—a phenomenon observed in the case of the Affordable Care Act (Legerski and Berg 2016) as well as Medicaid (Grogan and Park 2017). Understanding how programs do or do not become entrenched requires attention to the narrative dimension as well.

A close narrative examination of the two cases of the British and American health care states, and the within-case comparison of American Medicare and Medicaid, suggests that a strong institutional narrative can act as a bulwark against fundamental reform. In the UK, the dominant institutional narrative depicted the NHS as a proud national achievement, founded in adversity and faithfully preserved through periodic peril by its dedicated staff as a single institution, publicly accountable to citizens and providing comprehensive health care, universally and free at the point of service. The strength of that narrative established the boundaries within which changes in institutional logic could occur, through a history marked by policy cycling and periodic larger, faster changes. Similarly, the common core narrative of a cross-generational compact sealed by its founders has preserved the mission and identity of American Medicare through relentless partisan contests. Medicaid lacks a similar narrative, allowing for its incremental extension until that extension itself became the story.

This comparison is suggestive, not definitive; but its promise invites the application of a narrative lens to other cases of institutional entrenchment, to build a more substantial body of theory and evidence.

Acknowledgments

I am grateful for the insightful and constructive comments on earlier drafts of this article offered by Jim Morone, Eric Patashnik, Jon Oberlander, and two anonymous reviewers.

Notes

References