Medicare was one of the most successful civil rights laws in history

When Americans think of the seminal Civil Rights legislation of the 1960s, they think of laws like the 1964 Civil Rights Act and the 1965 Voting Rights Act. Yet, there is one piece of historic 1960s legislation that unleashed a powerful civil rights tool that rarely gets remembered as “civil rights” legislation: Medicare.

Hospitals desegregated — some almost overnight — worried that they would get cut off from Medicare funds. “White Only” signs came down, white-only facilities and segregated wards admitted patients without regard to race and Black clinicians received admitting privileges.

And yet, a racial healthcare crisis persists. Over the past two decades, Americans have made no progress in narrowing racial disparities in medical care, although we know more about them today than ever.

Black patients are less likely than white patients to receive pain medication, emergency cardiology care, lung cancer surgery, a kidney transplant, an appropriate mental health diagnosis and end-of-life home hospice care. Black people are disproportionately hospitalized for psychiatric services, excessively diagnosed with schizophrenia and more likely to have amputations. Surgery is more likely to kill Black patients, including children, than white patients, and Black mothers are three times as likely to die in childbirth as white mothers.

These disparities remain after accounting for other characteristics that influence health.

The history of Medicare, which turns 60 this year, offers a suggestion of how to rectify some of these problems. The desegregation of hospitals didn’t come when experts recognized that they were segregated, or even when courts declared such practices unlawful. Instead, the changes came when the government required hospitals to do better, verified compliance and withheld Medicare funding when they failed.

This transformation forged by Medicare was as unexpected as it was abrupt.

Hospitals, especially in the South, had been segregated before the Civil Rights Act. The federal government didn’t formally even document the practices and, in many cases, willfully ignored them.

Title VI of the 1964 Civil Rights Act aimed to address this problem. It prohibited discrimination in federally funded institutions. Medical school-affiliated hospital facilities, which received much of their funding from federal government training and research grants, quietly began taking steps toward integration. Yet, at all other facilities, passage of the law changed little.

Nationwide, but most dramatically in the South, Black patients continued to struggle to get care. Hospitals still hung “White” and “Colored” signs, separated patient records by race and shunted Black patients into basements or separate buildings, if they’d treat Black patients at all. Black women continued to give birth in dangerous conditions. Sometimes, while in labor, they had to solicit care from multiple white-only hospitals or facilities with limited beds for Black patients until one perhaps admitted them.

Civil rights organizations filed hundreds of Title VI complaints. Yet, the federal government had no staff assigned to enforce compliance. As a result, the complaints accomplished very little.

There were also several other impediments preventing progress. While healthcare facilities had long received federal funds through programs like the Hill-Burton Act, which paid for the construction of segregated hospitals, mostly in the South, Washington could not easily claw back federal dollars that had already been distributed to hospitals. Further, Title VI had no built-in enforcement mechanism. The Johnson administration, which in its first two years had been consumed with passing and implementing an array of ambitious legislation like the Civil Rights Act and the Voting Rights Act, was faced with going after individual hospitals on a case-by-case basis.

Everything changed after Congress passed Medicare in 1965. Urged on by civil rights organizations, John Gardner, secretary of the Department of Health, Education, and Welfare (HEW), announced that to receive Medicare dollars, hospitals must comply with the Civil Rights Act. The new health insurance program covered 19 million seniors and promised to pay billions to healthcare facilities — but only if they complied. To Gardner, it was an unprecedented enforcement tool.

HEW devised a process for determining compliance. Federal workers would inspect facilities. Were patients admitted and assigned the first bed available, regardless of race? Did hospitals extend admitting privileges to Black doctors? Were there disparities between their patient population’s racial composition and that of their service area?

Hospitals clearly in compliance would receive Medicare dollars. Others clearly out of compliance would not.

Gardner did not have enough HEW staff to dispatch to inspect the nation’s 4,000 hospitals. So he put out a call for federal employees willing to volunteer in his department and conduct inspections. Over 1,000 came forward including tax accountants, veterinarians and scientists.

In April 1966, civil rights movement activists trained them. Some violations would be obvious. That included “whites only” signs above entrances, bathrooms and in cafeterias, racially separate medical records and infants segregated by race.

But trainers warned that hospital administrators might disguise a facility as integrated for the visit. Some did. One put a white administrator in a patient gown in a room with a Black patient. Another placed four comatose patients, each a different race, next to each other.

Doing the “HEW shuffle” of fixing signs and shifting a few patients was insufficient, the inspectors explained. Facilities needed to be race-blind.

The combination of a strict standard coupled with inspections worked.

In three months, nearly all hospitals ended formal segregation and had been Title VI-certified as Medicare providers. After July 1, hospitals that had not been certified as Title VI compliant — those that lagged transforming their facility or refused on principle to do so — could not provide care for Medicare patients.

The lives of Black people in the South radically changed. Before the intervention Black infants below the Mason-Dixon line died at twice the rate of whites. By 1971, however, Black infant mortality halved, largely because they more readily received care for treatable conditions and their mothers had access to hospitals for the first time.

Yet, even as Medicare proved enormously successful in erasing formal segregation, racial stratification patterns remained apparent in hospitals throughout the U.S., exacerbated by residential segregation and referral networks systems.

Ironically, we know this from Medicare itself. The program has long served as a tool for researchers to investigate disparities in healthcare: beneficiaries share a common insurance which makes it easier to isolate inequities.

And racial separation persists among Medicare patients. Black Medicare patients are disproportionately treated at hospitals with fewer resources and worse outcomes. In some hospitals, certain teams treat only Black Medicare patients. Other teams treat only white ones.

Starting in 2003, Medicare Advantage expanded the enrollment of Medicare recipients in commercial insurance alternatives. In Medicare Advantage, the federal government pays insurance companies fixed amounts for each enrollee and the companies then manage benefits. These programs, separate and unequal, also expose racial double standards.

Even within the same Medicare Advantage plan, care is worse for Black and poor enrollees. Black enrollees tend to have worse follow-up care and chronic disease management than white enrollees. Additionally, they experience higher rates of preventable hospitalizations than white beneficiaries and are more likely to be readmitted.

The 60th anniversary of Medicare should remind us that our greatest advance in health equity came from enforceable commitments to providing equal care, regardless of race. Racial disparities in healthcare can be eliminated if the federal government requires compliance — and then enforces it.

For hospitals and physicians in 1966, equal treatment suddenly became a condition of financial survival. The immediate gains Black patients received suggest that if the federal government required healthcare systems and insurers to make real, measurable progress toward addressing racial health disparity, it would produce immediate and significant gains once more.

The question is whether Americans — and their government — are willing to demand such accountability as they did 60 years ago?

David Barton Smith is emeritus professor of health management and policy at Temple University. He was the recipient of a Robert Wood Johnson Health Policy Research Investigator Award and is author of three books and numerous articles related to this topic.

Leila Morsy is an economic justice research fellow at the Legal Defense Fund Thurgood Marshall Institute and a senior lecturer at Flinders University. She is writing a book about the history of the exclusion of Black doctors and its contemporary consequences.

Made by History takes readers beyond the headlines with articles written and edited by professional historians. Opinions expressed do not necessarily reflect the views of The Inquirer.