Tag: Obamacare

Posted on

What Is…Medical Racism?

In the post I wrote a few weeks ago on racial inequity in COVID-19 vaccinations, I alluded to the history of the abuse of people of color by the medical field as a reason that some people of color may feel hesitant about the vaccine.

While I think it was important to talk about medical racism in my post from a few weeks ago, I think it is also important to dedicate a post all by itself to this topic, especially given the amount of attention this term has gotten in the past couple of weeks. Additionally, since it is Black History Month, it seems particularly timely to talk about this term now. As such, while medical racism was not among the terms I had initially planned to cover in my “what is” blog posts, I think it is important to cover this term.

But what is medical racism, and how has it manifested itself over the years?

In short, medical racism is “the systematic and wide-spread racism against people of color within the medical system.”[1] Racism against people of color within the medical system has taken a variety of forms over the past several hundred years in the United States, including, but not limited, to: policies that affect health outcomes disproportionately in communities of color, the disparity in health care coverage by race, biases held by healthcare workers against people of color, the use of the medical field as a means of harming people of color, and disproportionate use of people of color for experimental purposes in medicine.

The form of medical racism that involves policies affecting health outcomes disproportionately in communities of color is wide-ranging. It involves everything from the fact that unsafe water is much more common in communities of color than in white communities[2] to the building of highways through Black communities[3] (highways that would have an impact of pollution on said communities that got these highways[4]). Some of these policies might not always have in mind the intentional harming of health outcomes for people of color (though the building of highways in Black communities was in many cases intentional), but the result of such policies is harming people in communities of color.

Speaking of things that can negatively affect health outcomes for communities of color, one thing that can cause this is the disparity in health care coverage by race. I talked about this issue in my “Obamacare and Race” post a number of weeks ago, as there are particularly high uninsured rates among American Indians, Hispanics, and Blacks in particular. To Former President Obama’s credit, Obamacare has made that disparity somewhat less stark than it used to be, but it’s a disparity that still exists.

Even when people of color have health insurance, though, sometimes the doctors and healthcare workers that insurance covers can have biases against people of color. Sometimes that bias is explicit, but sometimes it can be implicit too, such as implicit preferences for white patients over Black ones,[5] false beliefs about the nature of how Black bodies are,[6] and the fact that many doctors don’t believe their patients of color when they say they are in pain (an issue particularly prominent with Black women).[7] This form of medical racism comes up every now and again, but especially in light of the painful COVID-19 pandemic, it’s a form of medical racism that really needs to be talked about thoroughly.

Sometimes, the medical field is used as a means of harming people of color, whether it be denying medical treatment available to others, or using medical treatment as a means of harming others. Both things happened with the way the American government in the 1830s handled smallpox in Native American populations. Initially, Native Americans were denied the access to smallpox treatments that whites got. However, many Native American populations later got this access when smallpox threatened removal of said populations to other lands.[8] In other words, denial of the smallpox treatments was initially used to harm Native Americans through suffering without medication, and then distribution of them was used to help accelerate the infamous Indian removals of the 1830s. I am sure there are other examples of this form of medical racism, but the example talked about in this paragraph is one that needs to be talked about more, in my humble opinion.

The final form of medical racism that I think is worth talking about is one that involves the disproportionate use of people of color for experimental purposes in medicine. This is when experimental medicines that are, these days, typically tested with a cross-section of people or with other animals get tested disproportionately on people of color. It was this form of medical racism that led to the exploitation of Black slaves in the medical field for the purposes of experimenting.[9] This form of medical racism was also involved in the “Tuskegee Study of Untreated Syphilis in the Negro Male,” a study where researchers told the people involved that they were being treated for “bad blood,” but in reality did not get treatment during what was a highly unethical and ultimately lethal study.[10] Some in the medical field suspect that many people of color are hesitant to participate in medical studies these days because of the legacy of how such experimental studies did so much harm to many people of color.[11]

The form of medical racism that seems to be talked about the most these days is the disproportionate use of people of color for experimental purposes in medicine. However, the reality is that medical racism can take so many other forms, as well—forms that ultimately can contribute to negative health outcomes.

[1] https://www.ywcaworks.org/blogs/firesteel/tue-07212020-0947/what-medical-racism

[2] https://www.nrdc.org/stories/unsafe-water-more-common-communities-color

[3] https://www.theguardian.com/cities/2018/feb/21/roads-nowhere-infrastructure-american-inequality

[4] https://www.lung.org/clean-air/outdoors/who-is-at-risk/highways

[5] https://www.businessinsider.com/biases-you-didnt-know-existed-in-the-medical-industry-2020-4#black-people-are-24-times-more-likely-to-die-from-the-coronavirus-4

[6] A study in 2016 found that half of white medical trainees held false race-based beliefs such as Blacks having thicker skin than whites: https://www.pnas.org/content/113/16/4296

[7] https://www.today.com/health/implicit-bias-medicine-how-it-hurts-black-women-t187866

[8] https://ais.arizona.edu/thesis/politics-disease-indian-vaccination-act-1832

[9] https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)32032-8/fulltext

[10] You can read about the long version of this story on the website of the Centers for Disease Control and Prevention: https://www.cdc.gov/tuskegee/timeline.htm

[11] https://www.npr.org/sections/health-shots/2017/10/25/556673640/scientists-work-to-overcome-legacy-of-tuskegee-study-henrietta-lacks

Posted on

Obamacare and Race

One of the signature issues for both major political parties is health care. Many Republicans want to repeal the Affordable Care Act, also known as Obamacare, that passed in 2010. President-elect Joe Biden, who was Vice President in the administration under which Obamacare was passed, says he wants to expand it. These are two wildly differing views on what to do with our health care system.

However, given the current climate of racial unrest in the United States, as well as the potential repeal of the law being considered by the United States Supreme Court, it seems timely to talk about Obamacare from a racial justice standpoint.

So, where does Obamacare stand from a racial justice standpoint? Well, I have some good news for proponents of Obamacare, and some not-as-good news:

Reductions in uninsured rates were significant among minorities.

Among the highlights of those gains:

  • 21.8% of American Indians and Alaska Natives were uninsured as of 2018, down from 32% in 2010.
  • 19% of Hispanics were uninsured as of 2018, down from 32.6% in 2010.
  • 11.5% of Blacks were uninsured as of 2018, down from 19.9% in 2010.
  • 9.3% of Native Hawaiians or Other Pacific Islanders were uninsured as of 2018, down from 17.9% in 2010.
  • 6.8% of Asians were uninsured as of 2018, down from 16.7% in 2010.[1]

These are undoubtedly significant gains. However…

The aforementioned gains I mentioned have stalled out.

Most of the gains that occurred were between 2014, when important provisions of Obamacare were implemented, and 2016. Those gains have stalled since then, and for Blacks the rate of those uninsured has started to tick up in recent years. The Kaiser Family Foundation, which focuses on health care issues, attributes this to certain policy changes in the Trump Administration “that affected the availability of and enrollment in coverage.”[2] But whatever the reason for this stall, it has happened, and this stalling trend is one that a President Biden will need to address (assuming the Supreme Court doesn’t repeal the law).

However, the gaps in insurance by race are about more than just what’s coming out of Washington, DC. It’s also because of policies at the state level.

Many states with large Black populations have refused to expand Medicaid under Obamacare.

As a result of this, even though there appear to be modest gains in racial disparities among the uninsured overall as a result of Obamacare, the gains are not as big as many might like. Additionally, the result of this is that about half of the remaining uninsured Americans are people of color.[3] This goes to show that elections have consequences—not just federal elections, but state ones too. This is worth keeping in mind for future elections at the state level.

In spite of the issues I’ve mentioned, the racial gap among the uninsured has closed somewhat.

The rate of those without insurance has dropped among whites too, but as there were fewer uninsured whites than uninsured people of any minority group to begin with, the rate among whites of those lacking insurance dropped more slowly than among any other racial group. As such, the racial gap among the uninsured has closed somewhat, even if there are disparities that still exist.[4]

In spite of all this data I’ve shared, there are some unanswered questions.

So far, I have painted a mixed picture of what Obamacare has been like for minority groups, particularly from an insurance coverage standpoint. But there are some unanswered questions about the true impacts of the health care law, too. Here are a few such questions:

  • While the number of uninsured Americans has decreased significantly since Obamacare was passed in 2010, the number of underinsured Americans has also increased.[5] To what extent does this underinsurance issue affect people of color?
  • Is there anything about Obamacare that might, even unintentionally, contribute to the continued (if somewhat decreased) gap in the uninsured between some minorities and whites?
  • There are mixed messages about how Obamacare affected health care costs—out-of-pocket health care spending decreased, while premiums increased.[6] To what extent are people of color getting the benefit of reduced health care spending, or the drain of increased premiums?

The unanswered questions are so numerous that I may need to republish this post at some point, as a version that hopefully answers some of the questions that I’m asking here.

Over the last several hundred words, I have painted a rather mixed message on the question of Obamacare and racial justice. But where does this leave us?

For those in the United States who care about American health care, this raises some questions. For the Republicans, who are proponents of repealing and replacing the law, how does the law get repealed and replaced without erasing all the gains that people of all races, particularly minorities, have seen as a result of Obamacare? For Biden and his supporters, how can we continue making progress in increasing the number of insured Americans, and how might the issues with underinsurance and health care premiums be addressed (assuming, once again, that the Supreme Court doesn’t strike down the whole law)? And for all sides of the debate on this law, how can we ensure that every American is insured?

The last question is maybe the most important one of all, because access to affordable health care should be a human right, not just a privilege to those fortunate enough to access it.

[1] https://www.kff.org/disparities-policy/issue-brief/changes-in-health-coverage-by-race-and-ethnicity-since-the-aca-2010-2018/

[2] Ibid.

[3] https://www.brookings.edu/blog/usc-brookings-schaeffer-on-health-policy/2020/02/19/there-are-clear-race-based-inequalities-in-health-insurance-and-health-outcomes/

[4] https://www.kff.org/disparities-policy/issue-brief/changes-in-health-coverage-by-race-and-ethnicity-since-the-aca-2010-2018/

[5] https://www.commonwealthfund.org/publications/issue-briefs/2019/feb/health-insurance-coverage-eight-years-after-aca

[6] https://www.cnbc.com/2018/01/22/out-of-pocket-health-spending-dropped-after-obamacare-rolled-out.html