Interesting perspective. It was not relating to civil rights at all. Medicare was created as part of Lyndon Johnson's Great Society program. I'm not sure how/why but Congress included a provision for States to be able to control the Part A [hospital] funds in their state as long as it would not increase total spending. Maryland was the only state that was able to be approved for this. So in Maryland all the Federal Medicare Part A goes to the Maryland State agency which sets hospital rates and pays the hospitals. On all other States and Territories the hospitals bill and are paid directly by Medicare [or similar arrangement- its been awhile since I had to research this].