Health Care Reform Center

Mona Sarfaty, M.D.

Edward M. Kennedy, the long-serving senior senator from Massachusetts who died on August 25, 2009, had a major impact on Americans who deliver or receive health care services and left a vast legacy to our health care system. Kennedy arrived in Congress in 1963 with a dedication to fairness, justice, and equal opportunity and a deep well of personal commitment and energy. He brought his values to bear on the policy areas of his Senate committee assignments, one of which was Health, Education, Labor, and Pensions. The result was an unswerving devotion to universal access to health care, enhanced education for health professionals, biomedical research and research ethics, and public health. 

Recognizing that many Americans were essentially excluded from the health care system, Kennedy worked persistently to expand access to care. His tenure began shortly before Medicare and Medicaid were voted into law, and over the years, whenever legislators sought to increase premiums or maintain limits on coverage, one could rely on Kennedy to stand up on the Senate floor and argue in favor of expanding coverage for services with proven benefits and protecting seniors from monetary barriers. He was an early supporter of expanding Medicaid to cover pregnant women and children and was later an original sponsor of the State Children’s Health Insurance Program (SCHIP). When he saw that access to care was limited in certain geographic areas and for some specific populations, he introduced legislation to create Community and Migrant Health Centers. This solution was developed close to his home — one of the two original community health centers was in Boston — and such centers now provide care to 17 million people throughout the country. He introduced the Emergency Medical Treatment and Active Labor Act (EMTALA), which stipulates that no patient may be turned away from a hospital emergency room but that every patient — even one who is uninsured or unwelcome — must be evaluated and his or her condition stabilized. Provisions such as the Consolidated Omnibus Budget Reconciliation Act (COBRA), which enables workers to retain health insurance after a job loss, emerged from Kennedy’s office, and he was a chief architect of the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act, the McKinney Homeless Assistance Act, and the Mental Health Parity Act. The Americans with Disabilities Act, which he and several other key legislators created and introduced, ensured that physical limitations would no longer be a barrier to entry to medical centers. In summary, he was instrumental in the creation of federal programs that now reach people of all ages throughout the country, especially Medicare, Medicaid, SCHIP, emergency room care, community health centers, health centers for migrant workers, and programs for people with HIV–AIDS and people who are homeless.

Although Kennedy was characterized by conservative groups as a doctrinaire liberal, in fact he wore no ideological straitjacket and famously worked with conservative Republicans in the Senate to find common ground. An activist and an innovator by nature, he invited a seemingly endless series of “legislative fellows” to join his staff and share their fresh ideas. These fellows were accomplished professionals from the executive branch or academic institutions. One of these fellows developed legislation for training programs in geriatric care; another developed legislation for advanced training of nurses.

Kennedy respected those who had expertise in the subjects under consideration and did not insist on being the smartest person in the room. He was the ultimate decision maker, but he was willing to listen to his staff debate until a consensus emerged or a correct answer was found. His political deftness was reflected in the skill he sought and found in his staff, advisors, and press secretaries. It was also reflected in high-quality hearings that resulted in effective media coverage: he always arranged for a layperson or “victim” to speak first, to crystallize the problem at hand by telling a personal story.

Kennedy recognized that biomedical research provides knowledge that is essential to improving health and took seriously his responsibility as chairman of the authorizing committee for the National Institutes of Health (NIH). Because the legal authority for the NIH must be renewed regularly, he was in a key position to oversee biomedical research. He assumed the role of the standard-bearer for passage of the National Cancer Act of 1971 after Senator Ralph Yarborough (D-TX) lost his Senate seat. It took many hearings and considerable persuasion to bring the research community around to supporting the bill. But it was typical of Kennedy’s grace and finesse that when the right opportunity arrived, he permitted a Republican to introduce the bill after the administration signaled that President Richard Nixon would support it only if it were seen as a Republican initiative.

In subsequent years, Kennedy held countless committee hearings that gave researchers a chance to address their own senators and to inform legislators and the public about scientific breakthroughs and opportunities. These were pivotal events for biomedical research. Kennedy also held the first Senate hearings on HIV–AIDS when other senators were afraid even to acknowledge the existence of the epidemic. Recognizing the danger of an infection that appeared to affect disfavored populations and that was already a cause of discrimination, he was one of the first to activate the legislative process to address the problem, introducing the first comprehensive bill that contained provisions for ground-breaking efforts such as community-based clinical trials and another that created a source of funding for medical care for people living with HIV–AIDS.

Kennedy appreciated the problems facing graduate medical education and put the challenge of the training of health professionals on his committee’s agenda. When the doctor shortage was identified during the Nixon years, the committee established a program that contributed to the growth of medical school classes around the country; later, hearings focused attention on oversized classes, and some schools reduced the size of their classes. Kennedy introduced and guided into law an initiative supporting institutions that traditionally trained black physicians and gave them an opportunity to become centers of excellence. He also introduced and protected programs that expanded training in new specialties such as geriatrics, preventive medicine, and modern primary care — and did the same for nursing through measures that supported advanced training for nurses. He pushed for a loan-repayment option within the National Health Service Corps scholarship program that resulted in the placement of health care professionals in rural or core-urban pockets of poverty.

Other areas in which Kennedy left indelible imprints include medical ethics, the integrity of the Food and Drug Administration (FDA), and the public health system. He was outspoken about keeping biomedical research within ethical bounds through the creation of the National Commission for the Protection of Human Subjects, a commission that was established in the wake of revelations about the infamous Tuskegee study, in which black men with syphilis were not given available treatment for the disease.

Kennedy’s commitment to public health and the regulatory structure that was required to maintain it also led him to become involved in virtually every FDA-related issue. He stepped forward to take leadership responsibility when a balanced consideration of various stakeholders’ positions was needed; his involvement in developing legislation pertaining to generic biologic agents or “biosimilars” is a current example.

Tobacco legislation was one of Kennedy’s important public health achievements. In 1990, he introduced the first comprehensive tobacco bill, which was designed to remove restrictions on state regulation of advertising, increase public education, and support states in reducing tobacco use by minors. The bill, signed into law by President Barack Obama this year, originated in the Senate with Kennedy’s efforts 20 years ago.

Depending on the outcome of the current debate on health care reform, Kennedy’s legacy to our health care system may be larger still. A major champion of national health insurance, he was active in every period in which enactment became plausible — the early 1970s, the early-to-mid-1990s, and the advent of the Obama administration in 2009. If reform occurs during this Congressional session, it will reflect the work that Kennedy and his staff began 2 years ago and his many efforts over the years to keep health and health care a vital part of the national agenda.

No potential conflict of interest relevant to this article was reported.

Source Information

From the Department of Family and Community Medicine and the School of Population Health, Thomas Jefferson University, Philadelphia.

This article (10.1056/NEJMp0908059) was published on September 30, 2009, at NEJM.org.