In June 1963, President John F. Kennedy urged the nation to take steps that guarantee equal treatment of all Americans regardless of race. This plea, addressing injustices against blacks, produced the Civil Rights Act of 1964, signed by President Lyndon Johnson on July 2, 1964. This landmark legislation outlawed discrimination based on race, color, religion, sex or national origin. It ended an unequal application of voter registration requirements and racial segregation in schools, the workplace and public facilities.
On its 50th anniversary, it is self-evident that the Civil Rights Act was moral legislation that confirmed our forefathers’ beliefs “that all men are created equal” and endowed with inalienable rights.” The moral certainty of today was not as obvious then, when the bill divided our nation, was debated and opposed vociferously (certainly worse than the debates involving the Affordable Care Act), and faced the longest Senate filibuster on record (60 days). The original House version was supported by members from the North (Democrats and Republicans, 283-34; Northern Republicans 138-24), and opposed by the Southern members (Southern Democrats, 7-87; Southern Republicans 0-10). The Senate version had a similar split, with only 1 of 22 Southerners voting in favor. The legacy of the Civil Rights Act continues to be a work in progress. But how times and moral perceptions have changed … or have they?
Consider our health care system. Should health care in the United States be an inalienable moral individual right and a component of social justice, as it is viewed today in all developed nations except us? If, as our forefathers wrote, all people are created equal, should not all also have equal access to the basic necessities of life, including health care?
The previous U.S. health care system left 50 million individuals uninsured and another 50 million with substandard insurance. The Affordable Care Act (ACA) marks the beginning of progress toward better health care for all. It incorporates many well-intended and long-overdue principles. And Medicaid expansion can save up to 90,000 lives annually. Whether the ACA will increase or reduce insurance premiums and the cost of health care overall is debatable, but the trends appear favorable: on average, insurance premiums are lower as is the overall cost of health care.
As with any well-intended large-scale endeavor, there were unforeseen consequences. The ACA limited the choice of health care providers. Half of the 50 million uninsured may still not gain insurance under the ACA; they include poor people who want to enroll in Medicaid in states that did not implement the Medicaid expansion, illegal immigrants, and people who decline to buy insurance. These issues could be remedied with subsequent legislation.
Opponents have generally criticized the implementation steps of the ACA, not its principles. Critics focused on the initial poor functioning of the healthcare.gov website and predicted that Americans and, in particular, young individuals may not sign up in sufficient numbers; that the ACA will discourage people from working; that it will increase the cost of health care and insurance premiums; and that disproportionate enrollment of sicker individuals will lead to a death spiral of the ACA.
Fortunately, these concerns have not materialized. About 8 million people signed up on the exchanges by the deadline of March 31, 4.5 million signed up for Medicaid under the ACA Medicaid expansion, and 3 million young adults (age 18-25) gained insurance under their parents’ coverage. Insurance premiums appear to be lower on average. The cost of the ACA is lower than anticipated. The number of people denied insurance is lower than publicized (perhaps less than 1 million rather than 12-15 million). The reported anecdotes and fears of health disasters were unfounded. And as more Americans experience the ACA’s benefits, more are in favor of it (49 percent to 48 percent in a recent ABC News-Washington Post poll), and more want to see the program improved (59 percent), not repealed.
The principles of the ACA are simple: extend health care benefits to all citizens and provide them with the best health care possible at affordable prices. After all, it is only by reducing health disparities that we can ensure that the nation’s children and citizens have an equal chance at competing for the American Dream. The ACA’s success will be measured by how broad the insurance umbrella is, and whether the legislation will ultimately improve the quality of care, reduce costs and save lives.
The ACA is a work in progress on a long and winding road that will hopefully lead our nation to better health care for all. It is inconceivable to imagine our nation today without the gains of the Civil Rights Act. It is impossible to understand why the issue was so divisive then, since it is such an obvious right and moral proposition. Similarly, let us hope we will look back at the ACA 20 years from now and wonder why it was such a contentious topic in 2014.
Hagop Kantarjian, MD, is chairman of the Leukemia Department at The University of Texas MD Anderson Cancer Center and a Baker Institute Scholar for Health Policy at Rice University.
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