The Racism Beneath America’s Health-Care Crisis

For generations, Americans have been told that our failure to guarantee health care is simply a disagreement about economics.

We are told that universal care costs too much. That government programs are inefficient. That private markets provide more choice. That people should be responsible for purchasing their own insurance. That health care is a commodity rather than a public obligation.

But that explanation leaves out one of the most important forces in American political history:

Race.

The United States did not merely forget to build a universal health-care system. It repeatedly made political choices that left millions of people outside the door. Those choices were shaped by insurance companies, organized medicine, employers, conservative ideology and fear of government power.

They were also shaped by racism.

The strongest historical argument is not that every person who ever opposed national health insurance secretly wanted Black Americans to die. History is rarely that simple, and exaggeration only weakens the truth.

The stronger and more defensible argument is this:

Again and again, many white Americans and political leaders resisted public programs when they believed Black Americans would benefit from them. They accepted a system that harmed working-class white people too, rather than support a truly universal system that would include everyone.

Heather McGhee describes this as America’s “zero-sum” racial bargain: the belief that progress for Black people must come at the expense of white people. In The Sum of Us, she uses the unforgettable example of towns that closed or drained their public swimming pools rather than integrate them. White communities destroyed something valuable for everyone rather than share it equally. (Time)

America’s health-care system can be understood through much the same lens.

Before Medicare, American medicine was openly segregated

For much of the twentieth century, racial discrimination was not hidden somewhere in the fine print of American health care. It was built directly into the system.

Black patients were turned away from hospitals, restricted to inferior wards or admitted only under segregated conditions. Black doctors were denied hospital privileges and excluded from many professional associations. Some communities maintained entirely separate hospitals because white institutions would not admit Black patients or physicians.

Researchers have documented that hospital segregation remained widespread into the 1960s and was legally sanctioned in many places. (PMC)

This meant that access to medical care depended not only on income, geography or insurance. It also depended on the color of a person’s skin.

The consequences were predictable: delayed treatment, inadequate facilities, fewer specialists, poorer maternal and infant care, and shorter lives.

That is the historical foundation beneath our modern system. We did not begin with equality and gradually develop disparities. We began with exclusion and have spent decades refusing to dismantle all of it.

Truman tried to make health care a national responsibility

President Harry Truman was the first sitting president to formally propose a broad national health-insurance program for the American people.

In November 1945, Truman called for a system that would cover medical, hospital, nursing, laboratory and dental services. He did not regard health care as a luxury reserved for people with good jobs or wealthy families. He viewed access to care as part of the nation’s responsibility to its citizens.

Truman continued to promote national health insurance during and after his successful 1948 campaign. His proposal, however, met furious opposition.

The American Medical Association conducted what was then one of the most expensive lobbying campaigns in American history. Opponents branded Truman’s plan “socialized medicine” and connected it to communism during the rising fear of the Cold War. By 1950, the proposal was dead. (The New Yorker)

Corporate interests and organized medicine clearly played enormous roles in that defeat.

But race also shaped the political environment.

Powerful Southern segregationist Democrats formed alliances with conservative Republicans to block federal social programs that threatened the racial order. Southern politicians feared that national standards and federal funding could interfere with segregated hospitals and local control.

This is where modern partisan labels can be misleading. During Truman’s era, many of the most committed white segregationists were Southern Democrats. Over the following decades, particularly after the national Democratic Party embraced civil rights, many white conservative voters and politicians shifted toward the Republican Party.

The resistance to equitable health care therefore cannot be understood simply as “Republicans have always done this and Democrats have always opposed it.” The deeper continuity is the conservative political coalition defending private power, states’ rights, local control and racial hierarchy.

The party alignment changed. Much of the underlying resistance survived.

Employer insurance created winners—and people left behind

During World War II, employer-sponsored health insurance expanded rapidly. Federal wage controls encouraged employers to use benefits, including health insurance, to attract workers. Tax policy later reinforced this arrangement.

Over time, America built a health-care system around employment instead of citizenship.

That decision had racial consequences.

Black workers had historically been excluded from many of the occupations most likely to offer stable wages, union protections and health benefits. They were disproportionately concentrated in agricultural labor, domestic work, service work and other jobs that frequently offered no insurance.

Research using historical data has found that Black households were significantly less likely than white households to purchase health insurance in the 1950s. (Cambridge University Press & Assessment)

This was not because Black families cared less about their health. It reflected lower wages, occupational segregation, discrimination and unequal access to jobs with benefits.

A supposedly “private” employment-based system therefore carried forward the inequalities of the labor market. When employment was segregated, insurance was unequal. When wages were unequal, access to doctors was unequal. When Black workers were excluded from economic opportunity, they were also excluded from medical security.

Medicare became an unexpected civil-rights weapon

After Truman’s plan failed, reformers narrowed their strategy. Rather than attempt to cover everyone, they focused on older Americans.

President Lyndon Johnson signed Medicare and Medicaid into law on July 30, 1965, at the Truman Library, with Harry Truman sitting beside him. Truman became Medicare’s first enrolled beneficiary—a symbolic recognition that the program was descended from his unfinished campaign. (National Archives)

Medicare did more than help senior citizens pay medical bills.

It helped desegregate American hospitals.

The Civil Rights Act of 1964 prohibited racial discrimination in institutions receiving federal funds. When Medicare began, hospitals had to comply with federal nondiscrimination requirements to receive Medicare payments.

The federal government inspected hospitals across the country. Hospitals that had excluded Black physicians, segregated patients or operated separate facilities faced a choice: integrate or lose access to a vast new stream of federal money.

Many institutions that had resisted moral appeals and legal challenges changed quickly when their finances were at stake.

Researchers have described Medicare’s implementation as one of the most important—and often overlooked—episodes of hospital desegregation. Even shortly before the program began, many Southern hospitals had not yet complied, and federal officials prepared contingency plans for patients who might be denied admission. (PMC)

This history reveals something crucial.

Federal health policy was capable of breaking apart a deeply entrenched system of racial discrimination. That is precisely why local control and private control had been so fiercely defended.

Why didn’t Medicare cover everyone?

Medicare was a monumental achievement, but it was also a compromise.

Rather than establish health care as a universal right, Congress created one program for older adults and another, Medicaid, for certain categories of low-income Americans. Most working-age people remained dependent upon employers, private insurance or their own ability to pay.

The final Medicare legislation was famously assembled as a “three-layer cake.” Hospital insurance became Medicare Part A. Voluntary physician coverage became Part B. Medicaid provided federal assistance through the states for some low-income people.

The arrangement was designed partly to overcome opposition from doctors, insurers, fiscal conservatives and legislators who feared a comprehensive federal program. (Time)

That compromise allowed millions of Americans to receive care. It also preserved fragmentation, state discretion and private-sector power.

Medicaid, in particular, was made dependent on federal-state cooperation. That meant the generosity and accessibility of coverage would vary greatly depending on where a person lived.

This structure was especially consequential in the South, where state officials had a long history of limiting public benefits and preserving racial hierarchy.

The truth about Medicare’s 20 percent

Under Original Medicare Part B, beneficiaries generally pay 20% of the Medicare-approved amount for covered outpatient services after meeting the annual deductible. (Medicare)

It is understandable that people look at that requirement and see a mechanism of exclusion. A 20% charge can be manageable for an affluent retiree and financially devastating for a senior living almost entirely on Social Security.

Cost-sharing unquestionably discourages people from seeking care. It disproportionately burdens people with low incomes and chronic illnesses. Because wealth and income in America remain deeply divided along racial lines, Black seniors may be less able to absorb deductibles, coinsurance, prescription expenses and uncovered services.

But I could not find credible historical evidence that the 20% figure was specifically created to prevent Black beneficiaries from receiving care or to reduce the Black population.

The documented legislative history points instead to compromise, cost sharing modeled partly on private insurance, concerns about federal spending and the political need to make the program acceptable to conservative lawmakers and organized medicine.

That does not make the consequences harmless.

A policy does not have to contain explicitly racist language to produce racially unequal results. A law can be presented as neutral while operating within a society in which wealth, employment, housing and health are already profoundly unequal.

This is the difference between proving an explicit racist motive and documenting structural racism.

We should not claim evidence we do not have. We should also not ignore the damage simply because racism was not written into the statute.

From Reagan to the Affordable Care Act

By the late twentieth century, overt defenses of segregation had become politically unacceptable. Racial politics did not disappear. The language changed.

Political messaging increasingly emphasized “welfare,” “dependency,” “taxpayers,” “personal responsibility,” “law and order” and undeserving recipients. Research has described this transition from open Jim Crow racism to symbolic or coded racial politics. (PMC)

Ronald Reagan helped popularize the image of the “welfare queen,” turning a highly distorted story into a racialized symbol of government waste. Although many beneficiaries of public programs were white, welfare became culturally associated with Black Americans.

That association helped generate support for cutting programs that benefited millions of struggling people of every race.

The same dynamic shaped health care.

Medicaid was portrayed not as insurance that protects children, disabled people, nursing-home residents and working families, but as assistance for people accused of taking something they had not earned.

When President Barack Obama pursued the Affordable Care Act, opposition was driven by many forces: partisan strategy, insurance and business interests, ideological resistance to federal power, misinformation and disagreements over mandates and spending.

Race was also part of the environment.

The ACA became attached to the nation’s first Black president and was quickly labeled “Obamacare.” Protest imagery, conspiracy theories about Obama’s citizenship and accusations that he was redistributing wealth to undeserving groups were impossible to separate entirely from America’s racial politics.

The law ultimately expanded coverage, prohibited insurers from denying people because of preexisting conditions, subsidized private plans and encouraged states to expand Medicaid.

Yet many Republican-led states refused Medicaid expansion for years, even though the federal government initially offered to cover nearly all the cost.

The people harmed included Black Americans, but also large numbers of white, rural and working-class residents.

Once again, the drained swimming pool appeared in a different form.

Rather than accept a shared public benefit that would include Black and brown Americans, political leaders rejected the benefit and left hospitals, families and entire communities worse off.

Racism harms Black Americans first—but not only Black Americans

Black Americans continue to face higher rates of maternal mortality, unequal treatment, medical mistrust, chronic illness and barriers to high-quality care. Historical discrimination in housing, education, employment and environmental policy compounds those health effects.

Even when Black patients have insurance, they may not receive equal care. Studies continue to find racial differences in hospital access, treatment, pain management and clinical decision-making.

But the tragedy does not stop there.

When racism is used to weaken public investment, millions of white Americans lose too.

Rural hospitals close. Families ration insulin. Seniors postpone dental and vision care. Workers remain trapped in jobs because leaving could mean losing insurance. Parents create online fundraisers to pay for cancer treatment. People die from conditions that could have been prevented or treated.

The United States spends extraordinary amounts of money on health care while leaving millions underinsured and financially frightened.

This is not simply an inefficient market.

It is a political system shaped by decisions about who belongs, who deserves help and whose suffering is considered acceptable.

We do not need a secret extermination plan to recognize the truth

There is a long and horrifying history of American eugenics, forced sterilization and medical experimentation involving Black people, Indigenous people, disabled people and poor women.

Those facts are documented. Eugenic ideas were promoted by respected institutions and influential leaders, not merely by obscure extremists. (National Human Genome Research Institute)

But I have not found reliable evidence of a legitimate study laying out a plan to eliminate Black Americans over generations by removing them from health insurance.

It is possible that the story being circulated blends together several real histories: eugenics, coerced sterilization, unequal health access, racial mortality gaps and modern efforts to cut Medicaid.

The resulting claim may feel believable because America’s documented history is already so appalling.

But facts matter, particularly when confronting systemic injustice. When we repeat something that cannot be substantiated, critics can use that one weakness to dismiss everything else.

We do not need to embellish the historical record.

The documented record is damning enough.

America allowed hospitals to segregate the sick.

It tied medical security to a labor market that excluded Black workers.

It defeated universal programs through coalitions that included segregationists.

It racialized public assistance.

It permitted states to limit care for poor people.

And it repeatedly accepted policies that damaged everyone rather than build inclusive institutions that might especially help those who had been historically denied access.

That is not a conspiracy theory.

That is American history.

The question now is whether health care will continue to be treated as a privilege distributed according to employment, wealth, geography and political power—or whether we will finally recognize it as part of the basic promise a democratic nation makes to its people.

Every person gets sick.

Every family eventually confronts aging, disability, injury, childbirth or loss.

Illness does not ask how we voted. Cancer does not check our race before entering the body. A heart attack does not care whether we have satisfied an insurance company’s paperwork.

Health care is one of the clearest places where our shared humanity should outweigh the politics of division.

And perhaps that is precisely why the struggle has lasted so long.

Because a country that guarantees care to everyone must first decide that everyone is worth caring for.

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Julie Bolejack, MBA

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