Medicaid 'Steeped' in the History of Structural Racism in the U.S, Say Authors


Founders of Medicaid had reason to fear that a state-run program would have limited ability to address the needs of vulnerable populations, say authors of Health Affairs piece.

Medicaid is often depicted as a tool for giving disadvantaged people access to healthcare, and the ACA enhanced its role even further in the states that have expanded the program. The Medicaid and CHIP Payment and Access Commission (MACPAC) estimates that between 2013 and 2020, Medicaid enrollment increased by 12.4 million in the Medicaid expansion states, which works out to about a 33% increase.

But a thought-provoking piece posted on the Health Affairs blog yesterday puts a different, starker light on the Medicaid program. While acknowledging its role as a safety net program, the authors say Medicaid’s history and politics are “steeped in the structural racism of the U.S.” and that its policies have “failed to resolve racial health disparities.”

“Evidence of this history remains a plain sight today,” they write. “For instance, elderly Black individuals are more likely to end up in nursing homes where Medicaid is the primary payer compared to their White counterparts.”

Their suggestions for improving Medicaid include putting an emphasis on diseases and conditions that disproportionately affect Black Americans, greater financial support for programs that encourage people of color to train to become healthcare professionals (based on evidence that healthcare improves when physicians and patients share the same race), and enforcement of Title VI of the 1964 Civil Rights Act that bans discrimination on the basis of race or national origin.

“Black patients have been fighting a battle for health equity and justice,” they write. “They deserve support in their fight for equitable healthcare, and this must start with policymakers reckoning with the more than 50-year history of failing to protect Black patients from racist policy decisions affecting the Medicaid program.’

The three authors of the piece are LaShyra T. Nolen, a Harvard Medical School student and the first Black woman to become class president there; Adam L. Beckman, also a Harvard Medical School student; and Emma Sandoe, the associate direct of strategy and planning at North Carolina Medicaid.

Here are some of the main points that Nolen, Beckman, and Sandoe make about Medicaid and its relationship to structural racism:

  • When Medicaid was created in 1965, almost all of the attention was on Medicare, the program for the elderly. It was set up as state-by-state program because Southern states fended off federal oversight because of the civil rights legislation of that era. State-run healthcare programs that preceded Medicaid, such as Kerr-Mills, were underfunded and few states participated, especially those in the South with large Black populations. “The founders of Medicaid had reason to fear that a state-run programwould have limited ability to care for vulnerable populations,” write Nolen, Beckman, and Sandoe.
  • Starting with the implantation of Medicare in 1966, the federal government pushed hospitals to desegregate. Nolen, Beckman and Sandoe write that enforcement of desegregation in nursing facilities for which Medicaid is the prime payer, was minimal and de facto desegregation continued. “Today, more than 50 years after the Civil Rights Act requirements, nursing facilities across the country continue to be segregated by race. This reality may have contributed to worse quality of care and poorer outcomes for Black elderly individual — and can be hypothesized as a likely contributor to the adverse outcomes observed in the older Black community during COVID-19.”
  • Welfare reform during the Clinton administrationseparated Medicaid eligibility from welfare eligibility (the main program then was called Aid to Families with Dependent Children). As result, write Nolen, Beckman and Sandoe, Medicaid enrollment decreased and has stayed low in states that haven’t updated eligibility standards.

In its 2012 National Federation of Independent Business vs. Sebelius decision, the Supreme Court made ACA Medicaid expansion optional. Of the 12 states that have not expanded Medicaid, seven are in the South (Alabama, Florida, Georgia, Mississippi, North Carolina, South Carolina, Tennessee and Texas) and most of those states have large Black populations.

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