Medicare: Truths and myths about origins, civil rights and the program's expansionary aspirations

This essay’s historical question is how and why the enforcement of civil rights came to be an important feature of the implementation of the Medicare statute starting in the summer of 1965.  The original formulation of the Medicare reform strategy--itself the subject of a number of scholarly books--placed no emphasis on desegregating Southern hospitals.  The strategy expressed at the start of 1965 emphasized the goal of 60 days of hospital insurance coverage for Americans over 65 and eligible for social security retirement benefits. By the time of implementation July 1 1966, the program administrators were preoccupied with avoiding criticism from senior citizens having difficulty gaining admission.  

How HEW leaders came to accept the use of Medicare's financial importance to press for desegregation –especially in Southern hospitals--is not widely understood in the historical and policy analytic literature.  The portrait of that process in this essay depends in large part on the author's role as assistant to Under Secretary Wilbur Cohen during the summer of 1966.  This participant observation is backed up by access to the files of Cohen and depends as well on the wider scholarship reflected in the book, The Politics of Medicare (1973, 2000).

The concluding theme is the surprise that civil rights enforcement was such a sensitive---and largely successful--initiative.  Medicare's social insurance reformers did not think of the program in that way; the Office of Civil Rights, itself a product of recent reform, was a spirited and demanding reform actor.  

By the time the program started, HEW and the White House were preoccupied with avoiding last minute disasters.  In short, the desegregation of American hospitals was precipitated by Medicare, but not because Medicare's leaders and key administrators had imagined that role for the program.  The role of myth --versus historical fact—is crucial.