:format(webp)/cdn.vox-cdn.com/uploads/chorus_image/image/59840629/GettyImages-96816088.0.0.jpg)
Michigan legislators recently voted in favor of Senate Bill 897, a law that requires Medicaid beneficiaries to work at least 29 hours per week or risk losing their health insurance. Though the bill contained exemptions for a range of subgroups, its work requirements were projected to apply to 700,000 people, and more than 100,000 of those were likely to lose health coverage.
If the legislation had passed as the Senate intended, its effects would have been racially lopsided. This is because the bill provided an exemption for residents of counties with high unemployment rates, without any similar relief for residents of cities with high unemployment. As a result, Medicaid beneficiaries living in high-poverty, mostly black cities like Detroit and Flint would have been required to work, while those living in mostly white rural counties would not.
Recently, in a marked change of direction, Republican Sen. Mike Shirkey (the bill’s sponsor) disclosed that the controversial race-based exemption would be dropped. Nevertheless, Shirkey refused to acknowledge that race mattered. Instead, he claimed that the “administrative nightmare” of tracking county unemployment rates on a monthly basis was untenable, while maintaining that allegations of racism were “ridiculous.”
The only thing that is ridiculous is Shirkey’s denial. Michigan’s initial attempt to pass a racially biased policy is no anomaly. Racism is deeply rooted in the past and present of the American health care system. The United States is a deadly, difficult and disempowering place for people of color, and health care policy plays a chief role in sustaining this state of affairs.
We’d have to go as far back as slavery to fully grasp the racial history of US health care, but I’ll start at a much more proximate place: 1946. On August 13 of that year, President Harry Truman signed the Hill-Burton Act (then known as the Hospital Survey and Construction Act). Hill-Burton was the first significant federal intervention into the domain of health care, and it was nothing short of pathbreaking. In 1948, nearly a quarter of all US counties had no hospital at all, and many more had a very limited supply of hospital beds. To address this problem, Hill-Burton provided hospital construction grants to communities that could demonstrate need and feasibility. As a result, the supply and utilization of public hospitals grew precipitously over the next 25 years.
But the benefits of this boom did not accrue equally to all Americans. In exchange for supporting the bipartisan Hill-Burton Act, Southern (segregationist) Democrats demanded that preexisting practices of racial segregation remain intact. Hill-Burton also gave rural areas priority consideration in the disbursement of funds, a move that concentrated the program’s resources most heavily in the South. Finally, Hill-Burton delegated the responsibility for assessing health needs to the states. Consequently, local (openly white supremacist) power structures tightly controlled the process of identifying disadvantaged communities.
Hill-Burton, the first substantial inroads the US government made into health care, was designed to reinforce segregation, while enriching and empowering local political actors who were zealously invested in oppressing black people.
Lest we think that all that racism stuff is behind us, let’s consider the present. Race rears its head in nearly every nook and cranny of the contemporary health policy landscape. Public opinion on the Affordable Care Act is profoundly racialized, in part because race-based evaluations of President Obama have “spilled over” into the arena of health care. Relatedly, there are gaping racial chasms in attitudes toward Medicaid expansion that diverge across states.
These rifts affect whether states expand the program. Two scholars from the University of Chicago recently found that states’ decisions about Medicaid expansion are “positively related to white opinion and do not respond to nonwhite support levels.” This has real consequences for people of color: Black and Latino people make up 48 percent of all Americans who fall into the “coverage gap” created by the states that refuse to expand Medicaid. Higher uninsured rates among these groups impede progress toward reducing yawning inequities in health outcomes ranging from maternal mortality to cancer to AIDS.
Medicaid work requirements build on this bedrock of racial inequality. There is persistent and well-documented racial discrimination in the low-wage labor market. One study found that an equally qualified African American is half as likely to receive a callback for an entry-level job compared to their white counterpart. When racial discrimination in hiring prevails, work requirements necessarily place a disproportionate burden on people of color.
Another significant barrier to employment is having a criminal record. But again, because of racism in the criminal justice system, black Americans are significantly more likely to have been incarcerated. This proves burdensome in the job market, even after people have paid their supposed “debt” to society.
Looking further down the line to when jobs are available and employers are willing to hire black folks, getting to those jobs can pose another significant challenge. Transportation infrastructure in communities of color is limited and often crumbling, so making it to work is no small feat. Though work requirements are race-neutral on their face, the tiniest glimpse into the skewed racial realities of navigating the labor market exposes them as discriminatory.
If all of the things I have said above are true, then perhaps people of color should flood the polls, the streets, and any other venue necessary to make their voices heard. Indeed, many of them have and will continue to fight for political change. Unfortunately, health policy itself can undermine those efforts. Policy and politics are linked. When policy is designed or administered in ways that are discriminatory, stingy, or unreliable, then the people meant to benefit from such policy are disempowered.
I wrote a book about the political effects of Medicaid. The black beneficiaries that I interviewed for my research would often (without prompting) relay stories of racial discrimination in Medicaid bureaucracies. One black woman from Michigan summed it up this way: “if you’re white and you have Medicaid ... you are looked upon with more sympathy. ... It’s ‘she’s going through a hard time right now.’ ... If it’s us … we are looking for a hand out ... and we are treated as such.”
Echoing this, a black woman from Georgia described the racial dynamics of Medicaid saying, “in that [Medicaid] office we’re in the bottom … all the way down there.”
These were common sentiments, and they did not just make beneficiaries feel bad, they made them distrust the government and sometimes caused them to disengage from politics.
Most broadly, the very structure of health policy in America undermines democracy. The patchwork of state Medicaid policies that emerge in the fragmented US political system has starkly different effects on the political participation of Medicaid beneficiaries in different locales. In some states, policy expansions boost rates of voting. In other states, policy retrenchment depresses political activity. Since places with large numbers of African Americans are less likely to expand Medicaid, these patterns do not bode well for political equality or democracy.
Nearly every aspect of the US health care system is shot through with racism. The latest debacle in Michigan is part and parcel of this larger reality. Reversing the biased policy that was originally proposed by the state Senate does not erase the enduring reality of race in America.
Achieving even a semblance of health equity in the United States requires both an unflinchingly reckoning with these facts and a more serious commitment to change than we have ever seen before. Such a commitment demands that we turn a skeptical eye toward waivers that purport to bring expansion while ushering in work requirements, drug testing, and other punitive policies. Not only are these waivers likely to exacerbate racial disparities in access to care, but they threaten to undermine our democracy.
With Medicaid facing persistent attacks and the entire social safety net under assault, broad and wide democratic engagement is vitally important, and pushing back against racially biased health policy is more essential than ever.
Jamila Michener is an assistant professor of government at Cornell University. She is a faculty affiliate of the Center for the Study of Inequality, the American Studies Program, and the Africana Studies Department.
