Grand Expectations: The United States, 1945-1974 (85 page)

It was not so clear, however, that there was such a thing as the "healing miracle of modern medicine." In the next few years death rates for people over 65 declined. So did rates of infant mortality. But these improvements merely sustained long-range trends, and it could not be proved that the extension of medical insurance—as opposed to other changes such as better nutrition—made much difference. "Medical miracles" were rare: the vast majority of patients with cancer, the nation's number two killer behind heart ailments, did no better after 1965. Infant mortality rates in the United States continued to be higher than those in many other nations, including some that were considerably poorer. They remained especially high among poor people and blacks, signifying the stubborn persistence of class and racial divisions in the United States.

Medicare and Medicaid, indeed, fell well short of national health insurance. They helped only the elderly and certain categories of the poor. Most Americans, including the working poor, had to contribute to employer-subsidized group insurance plans, to pay for private insurance on their own, or to do without. Those who lost their jobs often forfeited whatever coverage they may have had. And millions of people did do without. No other industrialized Western nation had higher percentages of its people—still about 15 percent in the early 1990s—without medical insurance.

Like aid to education, Medicare and Medicaid contained widely lamented flaws. One of these involved gaps in coverage. Medicare did not pay for many things, including eye glasses, dental care, and out-of-hospital drugs, and it did not cover long-term nursing-home care or the full costs of hospitalization. Deductibles grew increasingly expensive as the costs of care rose steeply over time. Ten years after the start of the program it was estimated that beneficiaries of Medicare spent as much on the average in constant dollars as they had done in 1964.
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The administration of Medicaid exposed special limitations. Like many other federal-state welfare programs—AFDC was the most salient example—it depended for its support on state legislatures, some of which (mostly those in the poorer states) could not or did not appropriate much money for the federal government to match. Huge variations in benefits arose from state to state.
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Like most services to poor people, Medicaid also tended to offer low-quality help. Many physicians shunned Medicaid patients, both because of the paperwork involved and because state governments tended increasingly to set reimbursements at a level below what doctors could receive from better-off patients. Some doctors ran so-called Medicaid mills that dispensed unnecessary services or charged for nonexistent procedures, thereby bilking public authorities and running up the costs to taxpayers. Dr. John Knowles, director of the Massachusetts General Hospital, said in 1969, "Medicaid has degenerated into merely a financing mechanism for the existing system of welfare medicine. . . . It perpetuates . . . the very costly, highly inefficient, inhuman and undignified means tests in the stale atmosphere of charity medicine carried out in many instances by marginal practitioners in marginal facilities."
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Critics of Medicare and Medicaid focused especially on the impact of the programs on medical costs, which rose rapidly as the programs expanded in the 1970s and 1980s. Cost increases, to be sure, had pre-dated 1965 and were rooted in the spread of private hospital insurance plans such as Blue Cross and Blue Shield after 1945. These plans had encouraged policy-owners to demand better (more expensive) care—after all, their premiums were supporting it. Doctors and hospitals were happy to offer high-tech services that other people—insurance companies—increasingly felt obliged to cover. Incentives for cost control weakened, and medical expenditures escalated. Between 1950 and 1965 hospital prices rose at the rate of 7 percent per year, compared to a rise in the general price level of 2 percent per year.
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Congress in 1965 might have seriously addressed these trends by imposing cost controls on doctors and hospitals providing Medicare or Medicaid services. But legislators who considered doing so faced the obdurate resistance of the AMA, which damned such controls as socialized medicine. Wilbur Mills and other congressional leaders had no stomach for a fight against such politically powerful constituents, and they approved entitlements without real controls. The law made it clear that hospitals and doctors should expect to be able to set their fees, with some exceptions. Costs then rose even more rapidly than they had in the preceding few years. During the next decade hospital prices jumped by 14 percent annually and physicians' fees by 7 percent.
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By the 1990s the costs of health care, driven upward in part by expenditures for Medicaid and Medicare, were inciting angry debates over the role of government in American life.

As it happened, the passage of Medicare and Medicaid in 1965 represented the only major governmental changes in the American health care system during the next three decades. Americans continued to live with a medical system that led the world in its training of physicians and in technological wizardry but that was also bureaucratically complicated and far from comprehensive. This was not the intention of Johnson and fellow liberals, who did well to secure legislation that reformers had been seeking for years. In 1965 they probably accomplished all that was politically possible. The power in Congress of pressure groups—insurance companies, doctors, hospitals—overwhelmed whatever support there was at the time (and it was weak) for a governmentally operated plan of national health insurance such as those that were instituted in many other Western nations during the postwar era.

Still, the exaggerations of Johnson and other liberals at the time came to haunt them within a few years. Talk about the "healing miracle of modern medicine" and about the capacity of Medicare and Medicaid to deliver it was as Utopian as talk about "wars" against poverty or the wonders of "compensatory education." Medicare and Medicaid survived to become important—and extraordinarily expensive—entitlements. But in time they raised widespread questions about the hyperbolic claims of Johnson and the wisdom of American liberalism.

Reform of the nation's immigration policies, the third of the Big Four in 1965, ranked lower among the priorities of Johnson and his advisers at the start of the legislative session. But congressional Democrats, led by Representative Emanuel Celler of New York, chose to seize upon the uniquely liberal mood to challenge existing immigration laws. These, dating from the 1920s, still employed "national origins" quotas that discriminated against southern and eastern Europeans and that sharply limited the numbers of Asians who could come to America.

By the close of the session they had succeeded, and Johnson traveled yet again, this time to the Statue of Liberty, to sign a bill that reflected the more rights-conscious spirit of the era. The legislation of 1965 did away with the old discriminatory quota system and established priorities that were expected to increase the flow of people from southern and eastern Europe—those, at least, who were not locked behind the iron curtain. It stipulated that a total of 290,000 immigrants per year (roughly the numbers then coming) could be admitted to the United States as of 1968. For the first time in United States history the law set limits on the numbers of immigrants who might be admitted from countries in the Western Hemisphere. These were to be 120,000 per year, with the rest—170,000—to come from Europe and (it was expected) in much smaller numbers from Africa and Asia. A maximum of 20,000 people might come from any single nation, except from those in the Western Hemisphere, where no such national limits were applied.
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At the time of its passage the new immigration law, while hailed for its repeal of the old quotas, did not seem likely to create major changes in the demography of the United States. Over time, however, it did; framers of the law failed to foresee the consequences of what they had done. This was mainly because the law also permitted the admission beyond numerical limits of close relatives of United States citizens, both native-born and naturalized. Over the next decade an average of some 100,000 were admitted each year in addition to the 290,000 authorized by the statute. Equally unexpected, the sources of immigration began to change dramatically after the late 1960s. Contrary to the expectations of Celler and others, the flow of immigrants from Europe declined after 1968. But the numbers from Latin America and Asia began to swell. By 1976 more than half of legal immigrants to the United States came from seven nations: Mexico, the Philippines, Korea, Cuba, Taiwan, India, and the Dominican Republic.
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These developments were hardly revolutionary at the time. The United States, with a population of 194 million in 1965 (and 205 million in 1970) easily absorbed the 400,000 or so legal immigrants per year who arrived in the late 1960s and early 1970s. Still, because the birth rate of other Americans had stabilized, immigrants came to compose a steadily higher percentage of the population. And the numbers of immigrants kept growing over time: by the late 1970s, more than 450,000 legal immigrants arrived each year, fewer than one-fifth of whom were Europeans. By 1980 the number of foreign-born people in the country had increased to 14 million, as opposed to 9.7 million in 1960. In the 1980s, an average of 730,000 legal immigrants came annually, of whom roughly one-tenth hailed from Europe.
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The vast majority of the rest (as well as large numbers of illegal immigrants) came from the Caribbean, Central and South America, and Asia.

As immigration mounted in the years after 1968, scholars and politicians debated whether the results justified the reform of 1965. Decades later there was no solid consensus on the matter. Critics insisted that the flow of migrants strained schools and social services and deprived native-born Americans, including blacks, of jobs. Others, stressing that the law gave priority to immigrants with skills, retorted that the newcomers contributed to economic growth. Proponents of more liberal immigration laws further welcomed the evolution of a richer ethno-cultural mix.
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These debates, however, focused on later, long-range consequences that had scarcely occurred to most people in 1965. What reformers saw at that time, and were happy about, was that they had abolished discriminatory quotas and opened up the gates a little to people around the world. Like much that cleared Congress in 1965, the immigration law reflected the hopefully liberal temper of the time.

The fourth and most significant liberal accomplishment of the 1965 congressional session involved the still most divisive issue of the age: race relations. This now focused on voting rights for blacks, which the civil rights acts of 1957, 1960, and 1964 had failed to guarantee. In many Deep South counties, 90 percent or more of blacks were not registered to vote. Johnson recognized the problem and called for action in his State of the Union message in January. He also anticipated, however, another southern filibuster—one that could tie up his Great Society programs—and he did not want to jeopardize other bills in order to fight for a voting rights bill early in the session.
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Civil rights activists, as so often in the 1960s, set their own agendas without consulting Washington. In January, Martin Luther King amassed SCLC supporters to demonstrate against the denial of voting rights in Selma, Alabama. Activists loyal to SNCC agreed to join, in part because the cause was so compelling. Selma, a city of 29,000 people, had some 15,000 blacks of voting age, of whom only 355 were registered to vote. Its board of registrars met only two times per month and blatantly discriminated against black people daring enough to appear before it. Blacks were disqualified if they neglected to cross a
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in registration forms or did not know the answers to obscure questions such as "What two rights does a person have after being indicted by a grand jury?"
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King selected Selma as his site for the same reason that he had shrewdly chosen Birmingham in 1963: he anticipated that whites would resist fiercely and violently, thereby dramatizing his cause on television and forcing the government to act. Like "Bull" Connor in Birmingham, Sheriff Jim Clark of Selma's Dallas County was expected to overreact. Clark was an unreconstructed segregationist who proudly displayed on his lapel a button, N
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, to tell blacks that nothing would change. With the approbation of George Wallace and of white leaders in Selma, he and his men had manhandled SNCC workers and would-be registrants in 1963 and 1964.

King judged his adversary accurately, for Clark and his deputies over-reacted in January and February 1965, arresting and jailing more than 3,000 demonstrators, including King and SNCC leader John Lewis. Deputies kicked and clubbed demonstrators and threw them into trucks that took them to jail. On one occasion Clark shoved a woman, who then knocked him down. Deputies threw her to the ground and pinned her, whereupon Clark leaned over her and smashed her with a club. Widely circulated photographs of this action appalled Americans around the country. On February 10 he arrested 165 protestors and pushed them on a three-mile forced march out of town. Electric cattle prods used by his men singed many of the demonstrators, who fell vomiting by the road-side. A few days later Clark punched the Reverend C. T. Vivian, an SCLC leader, and sent him reeling down the courthouse steps. State troopers, meanwhile, ambushed marchers in nearby Marion. When the troopers assaulted a black woman and her infirm father, her son, twenty-six-year-old Jimmy Lee Jackson, tried to intercede. He was shot in the stomach at close range by a trooper and died eight days later.
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