The Power to Heal: Civil Rights, Medicare, and the Struggle to Transform America's Health Care System by David Barton Smith (review)

Medicare just celebrated its fiftieth anniversary, and this book could not be more timely. But The Power to Heal is not about health insurance for the elderly. Instead, it is a detailed examination of how civil rights activists used the new Medicare program to end racial segregation in the nation's hospitals. The story, told by health policy scholar David Barton Smith, is a powerful reminder of the ability of citizens' action, in partnership with activist government, to transform society.

The book opens with an overview of the Jim Crow hospital system in the South—federally supported by the Hill-Burton Act's "separate but equal" provision—and pervasive de facto segregation in northern health care. Smith then introduces some of the main characters in his story: African American physicians who joined the civil rights struggle and became leaders in the fight for medical desegregation. He argues that physicians became the "backbone" of the movement due to their relatively privileged economic status and, ironically, to segregation itself: they were not beholden to white hospitals or the professional organizations that excluded them. Smith divides these activist-physicians into two categories: "street fighters," who engaged in direct action, and "Brahmins," who maneuvered using pressure tactics and lawsuits. His examples include both the celebrated (Montague Cobb, Brahmin) and the lesser-known (Sonnie Hereford III, street fighter).

One of these Brahmins, dentist George Simkins, brought a lawsuit against two segregated hospitals in Greensboro, North Carolina, that led to the landmark Simkins v. Moses Cone decision (1963), declaring Hill-Burton's separate but equal provision unconstitutional. Smith tells us how the Kennedy administration supported the plaintiffs, seeing this as a less risky way to tackle segregation than issuing an executive order. Although it is little recognized by historians, the Simkins decision, Smith argues, directly influenced debates on the Civil Rights Act and helped ease its passage.

Title VI of the 1964 Civil Rights Act prohibited federal funding to institutions practicing racial discrimination. After a failed attempt to use the measure to desegregate Chicago's public schools, federal officials became reluctant to pursue cases using Title VI, which, Smith argues, had "the ironic and unanticipated consequence of shifting control of enforcement into the hands of civil rights activists" (p. 95). After Medicare passed in July 1965, activists from the NAACP, the Medical Committee for Human Rights, and the National Medical Association volunteered to inspect hospitals in the South and began bringing Title VI complaints against segregated facilities. But individual cases would prove too slow. Recognizing this, Secretary of Health, Education, and Welfare John Gardner effectively converted his bureau into a civil rights enforcement agency.

The Office of Equal Health Opportunity was established within the Public Health Service in February 1966 to enforce Title VI compliance for any hospital that wanted to be part of the Medicare program. The office was staffed by federal employees who voluntarily requested temporary transfers to participate—the largest such transfer of government employees before or since, according to Smith. They faced the daunting task of ensuring that hospitals had ceased segregation and discrimination in all aspects of their businesses, from admissions to staff privileges to cafeterias. They had to accomplish this in just four months, before Medicare's implementation, and they were successful. On June 30, HEW declared that 94 percent of eligible facilities were Title VI compliant.

The story of how federal officials and civil rights workers accomplished this remarkable feat is compellingly told in the book's central chapters. Despite some resistance—including the suspicious shooting of an activist physician in Mobile, Alabama—southern hospitals rushed to desegregate. The contrast with "massive resistance" to school segregation is stunning, and explained, Smith argues, by hospitals' financial interests. Integration would not only bring hospitals desperately needed Medicare money, but save them the expense of running segregated facilities...