The ability to access quality health care services for the majority of the black population has been largely due to federal government policies and initiatives designed to address long-standing, systemic barriers to medical care for African Americans. As part of the White House’s Black History Month panel co-hosted by the Association for the Study for African American Life and History (ASALH) this past Wednesday, I had an opportunity to elaborate on this history by discussing the significance of the Affordable Care Act and rejection of the Medicaid expansion by southern states within the context of the ongoing struggle for health equity in the U.S.
While my research examines the interaction of racial politics with efforts to pass large-scale health reform from the New Deal to the ongoing opposition to the ACA, focusing on this year’s 50th anniversary of the passage of Medicare and Medicaid offered an opportunity to shine light on how important these programs have been in reducing the discrimination and institutional racism that were once hallmarks of American health care.
For a good part of the 20th century American health care was segregated and national health care policy like the Hill-Burton Hospital Construction Act was structured by powerful Southern legislators who used states’ rights as the guiding principle for incrementally expanding federal involvement in health care while maintaining “separate but equal” facilities throughout the South. The deeply entrenched Jim Crow system of segregated hospitals in the South often relegated blacks to substandard care and denial of admission to white hospitals even as black patients experienced life-threatening emergencies right outside their doors. Moreover, African American health care providers were excluded from membership in professional associations such as the American Medical Association that were crucially important for credentialing purposes and hospital admission privileges.
When Medicare went into effect in 1966, the Johnson administration used the Civil Rights Act as the basis for requiring hospitals to desegregate as a condition for receiving Medicare funds. By pulling this important policy lever, the Johnson administration ushered a relatively swift end to the Jim Crow hospital system in the South.
Medicare was a breakthrough in the long battle to achieve universalism in federal health care policy. Universalism as a principle means that every American has access to the same benefits. It is an important safe guard against discrimination and the nuances of state politics.
Years after Medicaid was enacted, however, legal action was still required as many hospitals continued to discriminate against African Americans and the poor by refusing to see patients covered by Medicaid. While racial discrimination in health care is illegal today, African Americans are especially affected by the Supreme Court’s decision to allow states to opt-out of expanding Medicaid under the ACA. With 24 states controlled by Republican governors or state legislators rejecting the Medicaid expansion, people in states that most need expanded coverage options due to higher rates of poverty are being locked out of the ACA. Most southern states are not expanding Medicaid, leaving nearly four million adults eligible for the program through the ACA without health insurance coverage. According to the Kaiser Family Foundation, forty percent of eligible African Americans reside in states not participating in the expansion. Because of the distribution of the African American population in the South and the greater likelihood of earning incomes that make them eligible for Medicaid, these state decisions disproportionately impact black southerners and are likely to increase health disparities as Americans in states that have expanded Medicaid experience the benefits associated with health care coverage.
As originally written, the ACA’s Medicaid expansion provides uniform eligibility requirements across the states by making adults with incomes at or below 138% of the poverty line eligible for coverage. With this provision, the nation was the closest it has ever been to implementing a national, universal health care program for poor adults.
Medicare and Medicaid have been important vehicles for ensuring access to care for seniors, the poor and other vulnerable populations. Both of these programs have been especially significant for African Americans as they not only helped to dismantle the Jim Crow health system but continue to serve as powerful public health tools for reducing racial disparities in health.
State Medicaid expansion decisions and their impact on communities of color point to the unfinished business in the fight to ensure equitable access to health care. The ACA has the potential to bring us closer to reducing the disparities in health care access that have far too long defined black life in America. Republican legislators and governors can play a crucial part in this effort by expanding Medicaid.