RACIAL JUSTICE DEMANDS MEDICAID EXPANSION IN THE SOUTH

Even as more organizations have been calling out racism in public health and medicine, some states are continuing to exacerbate health inequalities by not providing access to care for many of their most vulnerable residents, particularly those of color.

While 40 states have expanded Medicaid, 10 states have not – and most of those are in the South. This refusal to enact Medicaid expansion amounts to a refusal to ease the health care burden of some 3.5 million uninsured adults. Racial and social justice demands that these remaining states join the rest of the country in offering help to their most vulnerable citizens.

People want health insurance, and polling shows 57% of U.S. adults believe the federal government should be tasked with providing health care for all Americans. Research also shows generally positive outcomes from expanding Medicaid, a program jointly funded by the federal government and states. Yet even after a deadly global pandemic with a highly transmissible virus, a national housing crunch with soaring home prices, and rising inflation causing the cost of food to spike, there are still policymakers who refuse to take this needed step.

Of the 10 states that have not expanded Medicaid, seven are in the South: Alabama, Georgia, Florida, Mississippi, South Carolina, Tennessee and Texas. Ironically, Southern states are some of the hardest hit by interrelated issues like poverty, poor health care access and health disparities. And many states in the South are home to myriad communities with high social vulnerability, meaning they are more likely to suffer negative effects from a hazardous event like a disease outbreak.

Southern states are also home to some of the largest Black populations in the U.S., highlighting how expanding Medicaid in the South is clearly an issue of racial justice. In fact, according to a March analysis from KFF, more than 6 in 10 nonelderly adults who fall into the national coverage gap – meaning they live in a state that has not adopted Medicaid expansion and are not eligible for coverage through the program or for subsidies through the Affordable Care Act’s marketplaces – are people of color. Nearly all nonelderly adults in this coverage gap live in the South.

A similar case in point: If Mississippi expanded Medicaid, KFF data has shown Black and Hispanic people accounted for 55% of the uninsured adults who would be newly eligible for coverage, with whites accounting for 42%. This would be crucial for children and adults in the state, which is home to the nation’s highest rate of infant mortality, according to data from the Centers for Disease Control and Prevention.

In 2020, according to the state health department, Mississippi’s overall infant mortality rate was 8.3 deaths per 1,000 live births. Among Black babies, the rate was 11.8 per 1,000, compared with 5.7 among white infants. This appalling discrepancy is just one example of how withholding medical insurance is helping to lead Black people – and especially Black babies – to an early grave.

In short, in refusing to expand Medicaid, holdout states are perpetuating racism and continuing the legacy of slavery. The failure of expansion effectively serves as a strategy of racial oppression, carrying disturbing parallels to mechanisms of slavery in the antebellum South, with states benefiting from the labor of low-income residents and people of color while withholding access to care.

Another way in which we create a cycle of oppression and limit access to care is through inequitable reimbursement. We pay providers more to see patients with Medicare – insurance for older adults, certain younger people with disabilities and those with end-stage renal disease – than patients with Medicaid, which is insurance for those living with lower incomes and also can cover people with disabilities.

For example, primary care providers in Florida in 2019 were reimbursed at a rate of 49 cents to the dollar for seeing a patient with Medicaid compared with seeing someone on Medicare. Nationwide, primary care providers were reimbursed at a rate of 67 cents to the dollar for Medicaid versus Medicare patients.

But why can’t we reimburse for both social health insurance programs equally? In Florida’s case, by not expanding Medicaid to provide potential coverage to more than 700,000 people and by not setting a higher reimbursement rate that could incentivize more providers to treat Medicaid patients, the Sunshine State is fueling oppression.

Because these discrepancies disproportionately hurt people of color, it is no exaggeration to say that racism – exhibited through racially inequitable policies – literally makes people sick. North Carolina’s recent decision to embrace Medicaid expansion should serve as a wake-up call to other Southern states. And if legislators will not step up to end oppressive and unfair policies, then it is time for public health leaders – including community health workers and practitioners – to network with policymakers who value and follow public health science. Public health perspectives are needed in state capitals across the country – particularly in the American South – to bring about transformative change and empathy for the health of all Americans, regardless of their state of residence, race, income or education.

Public health leaders understand we need to create a culture of health that aims to promote social justice and dismantle inequitable practices, such as opposition to Medicaid expansion. Policies that harm communities disproportionately and unnecessarily have no place in America. They are undemocratic, unjust, oppressive and inhumane. In these ways, they are not unlike slavery.

These systems are an antithesis of public health, and they must change.

2023-06-07T17:25:19Z dg43tfdfdgfd