By Charles Zackary King | Changing Trends and Times | Healthcare Series, Part 3
Let me tell you about a woman I want you to picture. She lives in a rural county somewhere in this country, somewhere real, somewhere you could find on a map with no trouble. She is working two jobs, neither of which comes with employer-provided health insurance. She earns just enough money that the legacy Medicaid program in her state, a state that has chosen not to expand Medicaid under the Affordable Care Act, says she earns too much to qualify. She earns too little, however, to absorb marketplace premiums even after the subsidy that the ACA provides, because in the income bracket where she lives, that subsidy does not reach far enough to make a plan genuinely affordable once the deductible is factored in. She is, in the technical language of healthcare policy, in the coverage gap. In plain language, she has nothing.
She has had a persistent cough for three months. She has not gone to a doctor. The nearest physician who takes new patients without insurance is a 45-minute drive away, a drive she cannot make on a Tuesday morning without losing the shift she cannot afford to miss, at a job that does not offer sick days. She has not been to a doctor in four years. Her blood pressure is probably elevated, she felt dizzy last week, the kind of dizzy that you remember after it’s gone and file away without a name because naming it would require doing something about it. She doesn’t know what her blood pressure is because she has not been checked. She is not avoiding the doctor out of stubbornness or indifference or any failure of character. She is living inside a set of interlocking structural constraints that make a medical appointment genuinely inaccessible to her life as it is currently constructed.
This is not a story about bad choices. This is a story about what systemic barriers look like from the inside. And this is exactly where Part 3 of the Changing Trends and Times Healthcare Series lives.
A Hospital That Was Built to Exclude You
The Hill-Burton Act of 1946, passed under President Truman as a sweeping federal program to fund the construction of hospitals and health facilities across America, contained a provision that most of its celebratory press coverage did not lead with. That provision allowed hospitals in states operating under “separate but equal” segregation policies to receive federal construction funds and still legally exclude Black patients from full service, provided that theoretically equivalent care was available to Black patients in separate buildings or separate wards. In practice, “separate but equal” in hospital construction meant what it always meant in that era: inferior facilities built in Black communities, or no facilities at all.
From 1946 through 1965, billions of federal dollars flowed into building the physical infrastructure of American healthcare. Those hospitals were built in the places that could secure the political will and the local matching funds to receive them. They were built, in large part, in white communities. They were built, in large part, away from the communities whose residents were legally classified as separate and whose access to the resulting care was, in practice, severely limited even when not formally denied. When the Civil Rights Act of 1964 forced an end to formal segregation in federally funded facilities, the buildings were already standing. The deserts had already been drawn onto the map. That infrastructure did not evaporate when the law changed. Many of those same geographies are still healthcare deserts today. The hospitals are still where they were built. The communities that were built around, rather than served by, that infrastructure are still underserved.
The wall was built with federal money. With federal authorization. With the signature of a sitting president. You didn’t build it. You inherited it.
When the Map of Medicaid Looks Like a Map of Race
The Affordable Care Act’s Medicaid expansion provision was designed specifically to address the coverage gap I described in the opening of this post, the space between the people who earn too little for marketplace subsidies and the people who meet legacy Medicaid eligibility thresholds. The federal government offered to cover the cost of that expansion at a 90 percent federal match rate, which is an extraordinary financial arrangement for any state. And yet, by 2026, a significant number of states have still chosen not to expand Medicaid. Map those states. Look at where they are. They are concentrated in the South and in regions of the country with the highest proportions of Black, Indigenous, and low-income residents. That is not a coincidence that requires sophisticated statistical modeling to observe. It is visible to the naked eye on any coverage map produced by any policy organization working in this space.
The racial mathematics of non-expansion are not incidental to the policy debate. They are the predictable and documented outcome of political decisions made in legislatures where the populations most harmed by non-expansion have, historically and structurally, the least political representation and the least leverage over the outcome. The people living in the Medicaid coverage gap are disproportionately Black, Latino, and Indigenous. They are disproportionately working in the agricultural, domestic service, and gig economy sectors that the Southern and rural economy has always depended upon and that have always been structured to exclude from benefits. The system was theoretically redesigned to open its doors to these people. The doors are still closed. And the decision to keep them closed is made, year after year, in state capitols where these same residents pay taxes and produce economic output and remain politically underrepresented.
| “The wall between too many Americans and a doctor’s appointment is not made of moral failure or personal weakness. It is made of legislation, geography, and a history of decisions that built the healthcare system to serve some people and accommodate others.” |
Implicit Bias Walks Into the Room With You
The research on implicit bias in clinical settings is not emerging or preliminary. It is substantial, replicated across institutions and methodologies, and deeply uncomfortable for a medical profession that defines its identity around the principle of objectivity. Studies using patient vignette methodology in which physicians are presented with identical patient descriptions varying only in the documented race of the patient, have produced consistent findings across decades of research. Black patients are less likely to receive appropriate pain medication for equivalent diagnoses. They are less likely to be referred for cardiac catheterization when their clinical presentation indicates it. They are more likely to have their reported symptoms attributed to psychological causes rather than physical ones. They are more likely to be discharged sooner from emergency care settings. These are not the findings of one provocative study. They are replicated findings across multiple research designs and clinical contexts.
Consider what this means in terms of Black maternal health. Black women in America are dying in childbirth at two to three times the rate of white women, not primarily in underserved clinics or under-resourced settings, but in hospitals, attended by medical professionals. Serena Williams’s documented and widely reported experience of having to advocate forcefully and persistently for herself after delivery, insisting to clinical staff that something was wrong, being initially dismissed, and ultimately being diagnosed with a pulmonary embolism after she demanded specific intervention, is not an anecdote in the sense of being exceptional or isolated. It is a high-profile data point in a dataset of hundreds of thousands of clinical encounters every year in which Black patients, particularly Black women, have their reports of pain and their sense of their own bodies treated with measurably less urgency and credibility than equivalent reports from white patients. The research says so. The data says so. The deaths say so.
Geography Is Not Neutral
Healthcare deserts, counties and regions where the ratio of primary care physicians to population falls dramatically below any functional threshold for accessible care, are not randomly scattered across the American map. They are concentrated in rural areas, in low-income urban communities, in predominantly Black counties across the South, and in tribal lands across the West. This is not an accident of physician preference or economic market forces operating in a vacuum. It is the outcome of decades of policies affecting medical school funding, residency placement, loan repayment incentives, and hospital construction, policies that directed resources toward communities with political leverage and away from communities without it.
And the geography of environmental racism compounds this. Environmental racism, the documented, studied pattern by which industrial facilities, freight corridors, highway infrastructure, waste processing sites, and environmental hazards are disproportionately sited in low-income and majority-minority communities, creates health burdens that do not wait for a doctor’s appointment to manifest. A community with elevated rates of pediatric asthma from proximity to a heavily trafficked freight corridor, elevated rates of lead exposure from aging housing stock that has not been remediated, elevated rates of hypertension and cardiovascular disease from chronic environmental stress, and no primary care physician within 30 miles is not experiencing a coincidence or a run of bad luck. It is experiencing a system of geographic, economic, and environmental policy decisions whose cumulative effect, predictable and documented, is to concentrate sickness in the communities least equipped to access care for it.
| Part 3 of the Changing Trends and Times Healthcare Series names the wall. Parts 1 and 2 told you the history and the mental health crisis. Part 4 is going to talk about what we build in response. Watch Part 3. Share this post. Follow @ChangingTrendsAndTimes. These trends are changing because we refuse to accept the times as fixed. I’m Charles Zackary King. Let’s go. |
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