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Separate and Unequal

Posted on October 23, 2014

 In 1896, the Supreme Court ruled that Separate But Equal was constitutional in the Plessy v. Fergusoncase.  Over the following decades, constitutionally sanctioned racism and violence against African-Americans was allowed to continue in the South under the Jim Crow laws.  Finally, the other branches of government began to address the Court’s terrible mistake in the 1960s, with the Civil Rights Act of 1964 and Voting Rights Act of 1965.  It is hard to comprehend the damage done by the Supreme Court Justices when they continued to allow systemic discrimination against a whole race of people, just because of the color of their skin.

In June of 2012, I joined many others in celebrating the Supreme Court’s decision to uphold the Affordable Care Act’s (ACA) requirement for personal responsibility to obtain health insurance.  At the time, I believed that the decision would allow millions of people living in poverty to finally have access to health care that has been traditionally denied them due to their inability to pay.  Although this decision seems far from the single payer solution I believe we need, I initially saw the Court’s decision as a positive step toward treating health care as a human right.
As time has moved forward, I’ve started to see the decision’s dark side.  One part of the Court’s decision about the ACA reversed the requirement for states to expand Medicaid to all people living under the 138% of the Federal Poverty Level (FPL) (around $27,000 a year for a family of three). In reality, the Court’s decision has created a new systematic form of discrimination to emerge.  Those living under 138% FPL in Medicaid expansion states now have access to low cost health care.  However, cross the state line into a non-expansion state, and those in poverty are being denied access to the basic medical services they and their families need to maintain their health and well-being. 
As of this writing 21 states have decided not to expand Medicaid. While the decision of these state politicians affects all people living in poverty, it also exacerbates our long history of systematically discriminating against people of color.  To quote the Kaiser Family Foundation:
People of color have particularly high stakes in state decisions to expand, as over half of uninsured Hispanics and nearly two-thirds of uninsured Blacks and American Indians/Alaska Natives have incomes below the Medicaid expansion limit. The Medicaid expansion could significantly increase coverage rates for these groups and help reduce longstanding disparities in coverage. If a state does not implement the expansion, most of these individuals will be left without an affordable coverage option and likely remain uninsured, contributing to ongoing access problems and continuing disparities in coverage. – May 13, 2013
Like Plessy v. Ferguson, the 2012 the Supreme Court decision opened the door for systematic classism and racism at the state level.  Over a century removed from Plessy v. Ferguson, we have obviously not learned, or cared to acknowledge the lessons of our racist past. I struggle to understand how the Supreme Court could permit systems to exist that so clearly leave out the poor and people of color?  How can the state politicians take advantage of this mistake by the Court to vote to deny people of color and those in poverty the right to get basic medical care?
While I hope those who are making these decisions are not consciously racist or prejudiced against those in poverty, something looks strangely familiar about the map of Medicaid Expansion. With the exception of Arkansas, Kentucky, Maryland, and a few northern states, Medical Expansion and Slavery maps are unfortunately nearly identical.  I wonder if any of the Supreme Court Justices feel any sense of responsibility for enabling this Separate and Unequal treatment of the poor when it comes to a basic human need such as health care?
Almost as disturbing as this misguided decision by the Court is the lack of public outrage and coverage of this wide spread discrimination.  How can a country as wealthy as the United States so specifically discriminate against those under 138% FPL?  Non-expansion states have sent a clear message to this group that they do not deserve the same rights as those above 138% FPL, who are able to go into the local or nation insurance pools and can access health insurance, often at a discounted rate based on their income.
What if we denied people under 138% FPL the right to free speech?  It seems as though a country that once treated people as property and discriminated against them because of the color of their skin would be adverse to such concrete class discrimination based on income level.  Now income level is being put forth as an excuse to treat a whole group of people as second class citizens.  We have a historical sin that is being repeated in nearly half the states in the Union, yet where is the outrage?
Maybe it is because those in poverty have been systematically denied health care for years that this discrimination doesn’t seem as bad, just as Jim Crow seemed better than slavery.  Perhaps because more progressive states are working hard to figure out their own Medicaid expansions, attention isn’t being paid to those left behind. Or maybe the poor have lost their voice in their everyday struggle to survive a life in poverty.   
I am disappointed and heart broken.  It frustrates me that our Supreme Court lacks insight and historical perspective and once again failed to protect people of color and those without resources and power.  I’m disappointment in elected state officials, who continue legacies of discrimination and racism in their states, robbing those they are supposed to represent of their human rights.
For those of us in expansion states, we have a dual obligation.  First, we need to intensely focus on proving that Medicaid Expansion improves the physical, emotional, and financial health of people and communities.  Second, we need to do everything in our power, as Americans, to support the efforts of those in non-expansion states to get health care to those under 138% of FPL.  A country that promotes that all people are created equal” should not deny those in poverty the same rights and privileges as those with means and wealth. 


I would love to hear stories from both sides of the expansion l
ine.  For those in states that have expanded Medicaid, how has the ACA impacted the lives of your patients and clients?  For those in non-expansion states, how has the political environment in your states impacted your patients and clients?  Hopefully, through these stories, we will show that as Americans we all have a right to health care, no matter what state we live in.

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