By Walter Tsou, M.D.
Philadelphia Inquirer, July 30, 2015
By the early ’60s, America was in the throes of the civil rights movement led by its charismatic leader, Rev. Martin Luther King. Discrimination and Jim Crow laws applied not only to bus rides and dining rooms but also to hospital wings and doctors’ waiting rooms, which often had separate curtains for blacks and whites. As it turned out, separate but equal was a failure not only in education, but in health care, too. Well before we started to measure health disparities, it was well known that minorities suffered far worse health outcomes.
But nothing shook the nation quite like the assassination of John F. Kennedy in 1963. With the overwhelming mandate of completing Kennedy’s unfinished agenda, President Johnson signed the Civil Rights Act in 1964 and the laws creating Medicare and Medicaid in 1965. Led by Wilbur Cohen, who had been the Assistant Secretary of Legislation in the Department of Health, Education and Welfare (HEW) under Kennedy and later Secretary of that department under Johnson, the architects of these laws saw them as a first step toward true national health insurance. To those who created Medicare and Medicaid, national health insurance would not only be a way to end separate but equal in waiting rooms, but also to establish health care as a right of all Americans.
But there was strong opposition by southern legislators as well as many physicians and private insurers. As a result, Congress settled for health insurance only for the elderly (Medicare) and for the very poor who were aged, blind, or disabled (Medicaid). Because Medicare was designed as a companion program to Social Security, 20 million seniors were auto-enrolled in 1965 in one year. (Compare that to the disastrous enrollment problems in October 2014 with the ACA with its complex eligibility rules.)
Fifty years later, Medicare and Medicaid have proven themselves as the most successful health programs in American history. They have given hundreds of millions of Americans access to care and have allowed tens of millions of them to avoid bankruptcy due to medical debt. Equally important, Medicare ended physical separation by race in doctors’ waiting rooms in most of the South, although much provider racial discrimination still persists.
Unfortunately, the failure to enact true national health insurance for everyone has led to our current patchwork health care financing system that is unimaginably complex, bureaucratic, and inefficient. The system continues to base access to health care on employment, income, and disease category, which indirectly reflect race. Even today, the black infant mortality rate in the United States overall, as well as in Philadelphia, is more than twice the rate for whites.
Money wasted determining eligibility for coverage could be used to cover everyone. The amount of money wasted on administration in the United States is more than 40% higher per capita than in any other country in the world. It is more than enough to fully fund our schools, build bridges, and address other public priorities.
Wilbur Cohen, while defeated in his goal of achieving national health insurance for everyone, said that he believed in the “salami” approach — getting one slice at a time until there were enough of the pieces together to cover everyone. Fifty years later, it is time to make his dream a reality.
Dr. Walter Tsou is former Commissioner of the Department of Public Health for the City of Philadelphia and past president of the American Public Health Association. He is currently Adjunct Professor of Family and Community Health at the University of Pennsylvania.