Racism mars the history of health care in America. For years, black patients were relegated to separate — and appallingly unequal — hospitals and wards. Many were simply denied medical attention, either “dumped” into the care of other facilities or turned away at the hospital door.
Fifty years ago this week, that started to change as Lyndon B. Johnson signed into law two programs — Medicaid and Medicare — that constituted real progress in the cause of health care justice. For one, these programs greatly expanded health care access for the elderly and the poor, of all races. Also, building on years of civil rights work and legal challenges, Medicare was wielded to finally end explicit hospital segregation; hospitals hoping to become certified for the program were required to comply with Title VI of the Civil Rights Act.
Yet despite this important achievement, racial justice in health remains an aspiration, not an achievement.
After the death of Freddie Gray in April, and as the nation debated race and the criminal justice system, Americans were reminded of some disturbing racial inequalities in health. Not least among these were the differences in life expectancy between some of Baltimore’s segregated neighborhoods, which were as high as one to two decades. Meanwhile, across the nation, black males in 2010 had a life expectancy almost five years lower than white males; black women could expect to live three years fewer than white females.
In addition to inequalities in health outcomes (which have many roots), disparities persist in health care access. According to a 2013 report, blacks and Hispanics have substantially higher uninsured rates than whites. And while many are pinning their hopes on the Affordable Care Act to address such inequalities, the act won’t remedy the many deeply rooted racial injustices in America’s health care system.
The ACA’s primary instrument for increasing health coverage for people of color is the expansion of Medicaid to all those earning less than 138% of the federal poverty level. However, although Medicaid eligibility was meant to expand nationwide, the U.S. Supreme Court ruled that states could opt out. Some 19 states are doing exactly that.
Hopefully, with some combination of public shaming and political mobilization, common sense will prevail and Medicaid will be expanded nationwide. But even if the ACA’s Medicaid expansion reaches all 50 states, the program’s intrinsic weaknesses render it insufficient for reaching the goal of health care equality.
Most concerning is the problem of health care access. An audit of California’s Medicaid managed care system last month, for example, raised disturbing questions about the adequacy of doctor networks for program participants in that state. Nationally, limited access to particular treatments is another problem. Last month, a study revealed that state Medicaid programs are limiting coverage of sofosbuvir, a potentially life-saving medication for those with Hepatitis C, a chronic condition disproportionately affecting minorities. The investigators called these cost-saving restrictions — which do not appear to have been based on any official, professional clinical guidelines — a potential “human rights violation” because they prevented patients from obtaining needed care.
Unfortunately, the problem of health care inequality is not limited to Medicaid. As a recent study suggested, some Obamacare plans effectively discriminate on the basis of drug affordability for certain diseases, like HIV/AIDS. By categorizing medications for particular conditions in the highest co-payment “tier,” these plans price out patients with those ailments. These additional co-payments can result in thousands of dollars a year in extra expenses.
The reality is that people of color bear the brunt of a system that treats health care as a commodity at the same time as high out-of-pocket costs in the form of soaring deductibles become the norm. This point was underscored by the findings of the Commonwealth Fund, which found in 2014 that 31 million insured Americans were underinsured on the basis of high out-of-pocket expenses, which deter many from seeking treatment. Of course, these challenges affect everyone, but minority families may face particular distress.
We do not need to accept this status quo.
Just as Medicare helped spur hospital integration, it can usher in true universal health care — a single-payer system of “Medicare-For-All” — that will help lessen racial and class inequalities in health care. Such an expansion is consistent with the original goals of many advocates who created the 50-year-old program. But even as we expand Medicare to all, we must also improve it, including ending burdensome cost sharing requirements.
True universal health care cannot wait. Consider the tragic case of the late African-American Monroe Bird. This 21-year-old was shot by a private security guard in February, under some very disturbing circumstances. Though he was left paralyzed and critically ill, his private insurance plan denied him coverage for care in a rehabilitation facility. Bird returned home to be cared for by his family, who faced considerable financial stress in his complex care, owing up to $1 million in medical bills. Monroe died on June 30.
As we continue to confront the reality of structural racism in this country — where the criminal justice system disproportionately targets men and women of color, where the school-to-prison pipeline is the fate for far too many — we should also be aware that our for-profit-health care system continues to fail too many people.
Racial and economic inequalities are intimately interwoven. There is now a record number of billionaires, yet as Vox notes, infant mortality is higher in West Baltimore than in the West Bank. The United States remains the only advanced nation that routinely forces families to start GofundMe campaigns to pay for the medical treatment of their loved ones — and people of color are often bearing the brunt of this struggle. If we want to simultaneously improve American health care while opposing racial injustice, then let’s expand and improve Medicare, and guarantee just and equal health care for all.
