In 1960, Congress passed a forerunner to the Medicare bill called Kerr-Mills that provided federal funds for states to pay for medical care for the aged poor. The Kerr-Mills approach ultimately failed and was replaced by Medicare and Medicaid in 1965. However, some early proponents of Medicare and comprehensive health insurance in general such as Wilbur Cohen, one of the principal architects of Medicare, saw Kerr-Mills as a necessary step in the right direction.
Cohen recognized that before Medicare legislation could be enacted, the public and Congress had to get used to the idea of public funding of medical care. Once passed Kerr-Mills would establish the precident of finanicing medical care for the elderly with public dollars. Advocates of Medicare could then argue that their more comprehensive program was just a better way of carrying out the principles already established by Kerr-Mills.
Some people called Cohen’s incremental approach to passing legislation “salami slicing” Cohen would get one slice of the political salami then another and another. Eventually he would have enough for an entire policy sandwich. Cohen’s true accomplishment wasn’t just his expertise in getting individual slices of political salami but his ability to keep the final sandwich clearly in mind. He never lost sight of his final policy goal.
Salami slicing is an important tool for all who want to achieve policy revolutions. Policy revolutions are rarely built all at once but rather slowly, bit by bit and step-by-step. The real trick is to not lose sight of the ultimate goal. Each piece of political salami has to add to the ultimate policy sandwich. Cohen knew how to make that happen. After what happened in Massachusetts, maybe it’s time for Obama to start slicing some health reform salami.