WASHINGTON - When Congress passed the Medicare bill in 1965, President Lyndon B. Johnson flew with a passle of supportive lawmakers to Missouri so he could sign the bill at a table with former president Harry S Truman.

"It all started really with the man from Independence," Johnson said at the Truman Library ceremony, recalling the Missourian's spirited but unsuccessful effort two decades earlier to convince Congress to pass a national health-insurance plan. "The people . . . love and voted for Harry Truman, not because he gave them hell -- but because he gave them hope."

Given that Truman had been the first president to endorse a national health-insurance plan, it was appropriate that Johnson gave the 80-year-old former president the first Medicare card that day. But Medicare's national coverage for older Americans represented only part of what "Give 'em hell, Harry" had tried, and failed, to do.

The wider Truman plan, proposed in November 1945, ran into relentless attacks by congressional Republicans and the American Medical Association, which labeled the initiative as "socialized medicine." After a few years of fighting a losing battle, Truman abandoned his plan when the Korean War broke out.  (Click here to read the Truman Library and Museum’s summary of Truman’s health-care initiatives.)

Ever since, lawmakers have been dogged by political debates over health care, from the progressive 1960s surge that resulted in Medicare; to the stagnation of the next two decades; the failed effort by President Bill Clinton to forge a 1990s compromise; the addition of the expensive Medicare D prescription drug program in 2006; and President Barack Obama's razor-thin 2010 victory in passing the Affordable Care Act, which was ruled constitutional last week. 

While Truman contines to influence his home-state senators -- both of whom admire him, but for different reasons -- the positions of U.S. Sens. Claire McCaskill, D-Mo., and Roy Blunt, R-Mo., are diametrically opposed on the Affordable Care Act. And the changing currents of public opinion in Missouri, combined with the political evolution of Truman's home state from solidly blue to increasingly red, have cast the issue as a crucial one in this year's elections.

McCaskill, whose Senate office boasts giant Truman posters and a "Buck Stops Here" desk sign, opened a campaign office in Independence on Monday with a feisty attack on GOP opponents of the ACA. She had been a crucial Senate Democrat in voting for the health care bill in the waning days of 2009. 

Blunt, a former history teacher who claimed Truman's old office suite in the Russell building when he moved to the Senate last year, is a harsh critic of "Obamacare" who has vowed to try to repeal and "replace" it. The Truman suite's previous occupant was U.S. Sen. Christopher Kit Bond, a Republican who voted against Obama's health care law.

Here are the two current senators' positions on the ACA, followed by a brief history of how other national lawmakers from Missouri have fared on health-care issues in the six decades since Truman proposed his doomed national health plan -- which had a similar goal but different approach than the ACA.

McCaskill moves toward 'give 'em hell'

More than any other vote in her Senate term, McCaskill has caught flak from GOP rivals this election year for her ACA vote and defense of both the individual mandate and the bill's overall approach.

But McCaskill, in the wake of last week's Supreme Court ruling, signaled in Missouri appearances this week that she may adopt Truman's "give 'em hell" approach: accusing critics of spreading "distortions and lies" about the ACA; offering her take on its benefits; charging that a "repeal" of the health-care law would hurt Missourians; and contending that GOP conservatives want to privatize Medicare.

"They want to repeal being able to stay on your parents' policies until you're 26," McCaskill told a Sedalia group, according to a taped transcript. "They want to repeal the ability to get insurance if you have pre-existing conditions. They want to repeal free preventative care for people to make sure we cut down on the high cost of disease because they're not caught until late in the game."

As for the individual mandate -- under which people who fail to get health insurance would face an IRS-enforced penalty starting in 2014 -- McCaskill argues that it represent a penalty on a limited number of health "freeloaders" rather than a tax on most Americans.

As an example of "the only people that have to pay the penalty for not getting insurance," she cited "the guy who decides he'd rather buy a new Harley-Davidson than pay for health insurance. And then he lays it on the pavement out here and wants all of us to pay his health-care bill."

In an interview earlier this year, McCaskill told the Beacon that most people don't realize "how linked getting rid of pre-existing condition problems (is) with the individual mandate" -- which will add many Americans to the insurance pool. Explaining that ACA is not really a government program, she said: 

"These are all private insurance companies on the private market. So how can you mandate that an insurance company on the free market take the sickest people if you don’t provide more healthy people in the pool to keep the costs down?"

McCaskill conceded that "the individual mandate is very unpopular" in Missouri and that "a lot of Missourians think it is a government-run program. They don’t realize that the Missouri legislature has the ability, under this bill, to have it all right here in Missouri . . . through a state-run exchange of all private insurance companies -- not a public entity in the group."

In an appearance Sunday in Columbia, McCaskill told reporters that "most Missourians, once they understand what's really in this bill and not the lies that are being told about it -- they are going to like it."

She added: "For the first time, we're telling insurance companies that they need to spend the money they get on health care and not just on denying health care."

Blunt wants to repeal ACA and start over

On the other side of the health-care coin, Blunt went to Mercy hospital in Springfield on Monday to discuss the challenges of the current system and his support for repealing the ACA, which he views as extremely unpopular. 

"People have looked at this and they don't like it," Blunt told reporters shortly after Thursday's Supreme Court ruling. "This is the first piece of social legislation ever, that I'm aware of . . . that got less popular after it was passed rather than more popular."

As for the individual mandate, Blunt said the Supreme Court made it clear that its penalties against people who refuse to get health care are in reality a tax. That is likely to become a major theme in GOP campaigns against the ACA, which he said depends on "a huge tax increase." 

During his visit to Mercy Hospital, Blunt said the ACA is unaffordable and overly complex. "No more 2,600-page health-care solutions," the senator said, asserting that the law should be replaced with a series of smaller, targeted health-care bills that Republicans back. In the meantime, he said, the best way for Congress to slow the ACA is to cut the funding for implementing parts of the law.

While the GOP-controlled U.S. House will almost certainly vote to repeal the ACA in a show vote on July 11, Blunt and other Senate GOP leaders realize that such an initiative will die in the Democratic-led Senate, so they are pinning their hopes on the GOP winning enough Senate seats in the November elections that the new Congress in January could approve a repeal. 

Jobs and the economy are likely to be bigger issues, but Blunt predicted that the Supreme Court decision will spur more action by ACA opponents than supporters. "This probably further energizes people who believe this is a bad idea and we can't afford it," the senator said.

Like many Republicans, Blunt -- who supports Medicare -- is not terribly specific on what he would propose to replace the ACA. "There are clearly things we could do to make the current health-care system work better, that don't involve a government takeover of health care," he said.

"I'm glad to talk about those [alternatives] as long as anybody is willing to listen," he added, ticking off a list of GOP proposals that include "small busines health plans, buying [insurance] across state lines, medical liability reform, equitable tax treatment, more health information available that patients ... can share with whatever doctor they are seeing." 

Blunt deferred to the state Legislature on whether Missouri should set up a state health exchange, but he said he suspected that the legislators would take advantage of the Supreme Court's decision to allow states to refuse to expand their Medicaid rolls without penalties. 

"The average state spends 24 percent of its budget on Medicaid. Next year, the average state is going to spend 29 percent of its budget on Medicaid," he said. "That's before these individuals are going to have to be added" under ACA.

Blunt added: "My guess is not very many states, including ours, will do that. But they'll have to decide that in Jefferson City, just like they'll have to decide the best way to approach the exchange – if this bill still stands."

From Truman's plan to the ACA 

Election-year debates on health care have been a tradition since Truman, although the importance of the issue has waxed and waned over the decades. 

Back in 1945, Truman first proposed a national health-insurance fund to be run by the federal government. While open to everyone, the fund would have been optional, with participants paying monthly fees and the government covering the cost of services provided by doctors who took part.

"Millions of our citizens do not now have a full measure of opportunity to achieve and to enjoy good health," Truman said. "Millions do not now have protection or security against the economic effects of sickness. And the time has now arrived for action to help them attain that opportunity and to help them get that protection."

After the plan was presented to Congress, the AMA and its Republican allies used the spectre of communism to attack Truman's plan as "socialized medicine" -- at one point calling White House staffers "followers of the party line." 

Truman and his congressional allies fought back, with the president vowing to a Missouri political adviser that -- if his plan proved unpopular with voters -- he would "cram it down their throats." But once the Korean War broke out in 1950, Truman abandoned the health-care effort, which went nowhere during the Eisenhower years.

In his book, "Dead on Arrival: The Politics of Health Care in 20th Century America," Colin Gordon outlines the ebbs and flows of health-care initiatives -- from political posturing to actual achievements like Medicare, a concept developed under President John F. Kennedy but rammed through Congress by Johnson, a former Senate majority leader.

When Johnson traveled to the Truman library in 1965 to sign the Medicare bill and give Truman the first card, both of Missouri's senators -- Democrats Stuart Symington and Edward Long -- stood with them on stage. It was a no-brainer back then, when Missouri was still a solidly blue state.

"This is an important hour for the nation, for those of our citizens who have completed their tour of duty and have moved to the sidelines," Truman said of Medicare that day. "These people . . . are entitled, among other benefits, to the best medical protection available."

Johnson said he was proud to have finally gotten Medicare passed, but said "it was really Harry Truman of Missouri who planted the seeds of compassion and duty which have today flowered into care for the sick, and serenity for the fearful."

Three years later, the costs of Medicare became an issue when Thomas F. Eagleton -- who had unseated incumbent Long in the Democratic primary -- fought a tough battle in 1968 against conservative U.S. Rep. Thomas B. Curtis, R-St. Louis County. While Curtis was a staunch opponent of Medicare, Eagleton supported it -- and won by a narrow margin.

While Medicaid came into being shortly after Medicare, Gordon writes that the concept of national health insurance languished during the 1970s and '80s. President Jimmy Carter's administration did not have the support to pursue a further expansion of national health care and President Ronald Reagan wasn't really interested. 

When then-First Lady Hillary Clinton sought to negotiate a major health reform deal early in her husband's first term, two of the Republican senators she tried to win over were Missourians: U.S. Sens. John C. Danforth and Christopher "Kit" Bond.

At a bipartisan health-care forum in October 1993, Hillary Clinton quoted Truman when she made the argument for universal health coverage. At the time, both Danforth and Bond were supporting a bill advocated by a fellow Republican, U.S. Sen. John Chafee of Rhode Island, that included a version of the individual mandate -- which had originated at a conservative think-tank.

The New York Times reported that Danforth was "friendly if noncommittal on her approach," quoting him as saying: "There are points of disagreement, but it's easy to overemphasize them." Bond praised Clinton's willingness to compromise but criticized her approach as overly "bureaucratic. There are these massive health alliances."

But Clinton's health-care initiative failed, and not much happened until Medicare D -- a budget-busting advance that President George W. Bush convinced Congress to back in 2005 -- and then the Affordable Care Act, 

The Senate passed the ACA the day before Christmas in 2009 in a 60-39 vote, with all Democrats and two Independents supporting it and all but one Republican voting no. It passed the House the following March by a 219-212 vote, with 34 Democrats and all 178 Republicans voting no.

In the two years since then, the split between Republicans and Democrats on health care has deepened with the influence of tea party groups who are adamantly against the individual mandate.

That deep division hasn't changed since last week's Supreme Court decision. A CNN poll released Monday showed an even split between those who agreed or disagreed with the court ruling, and a Kaiser Family Foundation survey showed 47 percent approving and 43 percent disapproving. Yet another poll, from the Pew Research Center, found 40 percent disagreed with the court's ruling versus 36 percent who approved.

Further details from the CNN survey indicate that most Americans under 50 agreed with the court, but most over 50 disagreed. More than 80 percent of Democrats agreed; about the same percentage of Republicans disagreed. As for Independents, they split about 50-50.

In the end, political analysts tend to agree, the future of the ACA will be determined by voters. If Obama is reelected and Democrats retain control of the Senate, the law's future seems assured. But a Republican takeover of the White House and the Senate would seem to doom the health-care law.

"If people want to continue with this health-care plan, one way to do it is to continue with the president in office for another term and Democrats controlling the Senate," Blunt said. "Elections have consequences."