How racism caused America’s expensive health care crisis

Estimated read time 12 min read

This is part one of a two-part series on racism in health care.

Despite being the sole high-income nation in the world without universal health care, the United States government refuses to recognize basic medical care as a fundamental right for all its citizens. In fact, about 8% of the country is uninsured, not to mention those who have insurance but don’t have the coverage they need.

Conservatives have always fought against universal health care, but why? It can be directly traced back to deep-rooted racist beliefs that have shaped our nation’s history. It’s the reason multiple prior efforts at obtaining universal health care have failed for over 100 years. 

Earnest efforts to have some form of universal government-funded health care like our European counterparts started in the late 19th century, long after slavery had ended. This coincided with insurance companies trying to bolster unfounded but popular beliefs that Black Americans were uninsurable. In fact, as you’ll see, one such publication made a claim that the so-called “Negro Problem” would be solved by denying them health care because they would die off quickly due to their race’s supposed “proclivity to disease and death.” Sadly, when faced with the choice of providing health care for all or health care for none—as long as it meant eradicating Black Americans—many chose the latter. 

In this first part, we’ll delve into the historical roots of racism and medicine and how it has defeated every attempt at universal health care, including the conservative’s modern ongoing war against Medicaid expansion in the former Confederate states. In the second part, we will discuss what’s being done to help overcome this historic injustice.

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In stark contrast to other developed nations, the United States stands alone with leaving citizens to fend for themselves on health care. At the very least, one would think that a silver lining to this cruelty would be that our government would be able to save billions of dollars per year, but in fact, the opposite is true; The United States spends more on health care per person than any other nation on the planet, while simultaneously being the only industrialized nation that doesn’t guarantee the most basic health care. Even worse, most citizens who do have health care coverage find it woefully inadequate. Insurance often has extremely high deductibles in the thousands to be paid before coverage can even begin, and that’s only if the medically necessary procedures are approved. 

Health care disparities trace back to the post-Civil War era. Ironically, when enslaved people were regarded as property, they were heavily insured. External assessments represented the market value in terms of a sale price for their human flesh, negotiated in a competitive market. This often marked the highest price paid for them as commodities.

the book that started it all

Prudential headquarters

As free men and women, however, they were suddenly regarded as uninsurable thanks to “Race Traits and Tendencies of the American Negro,” a book written by 27-year old statistician and devoted white supremacist Frederick L. Hoffman. He was commissioned to write the 330-page publication by Prudential Insurance company, and it was designed to prove—using a faulty statistical model—that the American Negro could not be insured.

By any metric, the publication was a huge success. It was distributed by major publishers in Britain and the U.S., and reviews of the book during that time period were positive. The book was also published in the prestigious “Publications of the American Economic Association,” which catapulted Hoffman to world prominence.  

The book was published in 1896, the same year the Supreme Court legalized segregation. The thesis of the publication was that Black Americans had inferior genes and got sick more easily than the white race. Yet the most egregious claim Hoffman posited was that if Black Americans could simply be denied access to health care for just three generations, their entire race would be wiped out.

Sadly, this racist book left an indelible mark on public perception and legislative efforts to establish universal health care. Lawmakers even used the book to argue that African Americans were so ill-suited to freedom that their entire race would soon be extinct. Furthermore, Hoffman’s racist work had a huge impact in the field of actuarial science, the discipline that applies statistical models to assess risk in the insurance industry. Because Hoffman embedded his racial ideology within his approach to the actuarial data, its sad legacy still remains within this field today.

Hoffman applied circular logic, writing that Black people died early because they were inferior, and they were inferior because they died early. “It is not in the conditions of life, but in the race traits and tendencies that we find the causes of excessive mortality,” which was the main tenet of the entire text. The book ignored all other factors, such as the impact of economic and social discrimination, with the sole exception of race. 

However, with many Southern conservative politicians and their white constituents unhappy that Black Americans were now equal citizens among them, they had every motive to try to deny them health care believing it would cause their end.

As a result, insurance companies either outright denied Black Americans coverage or charged them much more than their white counterparts. Even those that were charged more were only paid out with one-third less than the same plans held by whites. This was policy across the insurance industry, which also blocked agents from soliciting Black customers. They even denied commissions for any policy issued to them:

The public largely accepted the statistical explanation for unequal coverage. The insurer’s job was to calculate risk. Race was merely another variable like occupation or geographic location. As one trade publication put it in 1891: “Life insurance companies are not negro-maniacs, they are business institutions…there is no sentiment and there are no politics in it.”

Black Americans suffered greatly as a result. There was a high infectious mortality in southern cities driven primarily by extremely high infectious mortality amongst the Black communities. In fact, from 1906 to 1920, African Americans in cities experienced a rate of death from infectious disease greater than what urban whites experienced during the 1918 flu pandemic. This only led to further justification from politicians and officials that this demographic was prone to sickness and expensive to insure. 

the fight for coverage

In reality, as the South’s economy shifted from enslaved to free market labor, previously enslaved individuals had no place to get health care coverage. Finding employment was very difficult and even those able to find jobs did not have health care coverage included in their contracts. In addition, President Andrew Johnson’s administration explicitly stated that the federal government had no responsibility to care for the four million newly freed citizens. With the extremely low wages many Black Americans were given, who mostly worked in agriculture, they could simply not afford health care. 

As a result, this led to cramped and unsanitary living conditions. Freed people faced starvation, and diseases spread rapidly, leading to epidemics such as the smallpox outbreak in the fall of 1865. Fearing that this outbreak might impact the white citizenry, only then did the federal government get involved, and established the medical division of the Freedmen’s Bureau. This was was our nation’s first federal health care program. 

Emergency operating room of the Freedmen’s Bureau Hospital in Washington, D.C. This was the only one to survive into the 20th century. It would later transition to Howard University, an HBCU.

Government officials deployed just a little over 100 doctors across the entire war-ravaged South. Pleas for personnel and equipment were ignored. The number of doctors employed by the bureau was low, and soon the number was reduced to only 80 doctors serving 12 hospitals to treat four million people. Death rates in Black communities went through the roof, but pleas for help fell on deaf ears. 

One of those pleas came from Doctor Rebecca Lee Crumpler, America’s first Black female physician. She was born free, trained at the New England Female Medical College in Boston, and practiced medicine in Richmond, Virginia, after the Civil War. She would later join the Freedman’s Bureau to treat Black communities in the South. She published an essay advocating for help from politicians, saying “they seem to forget there is a cause for every ailment and that it may be in their power to remove it.” Unfortunately, the bigotry was too strong to overcome. Most Freedmen’s hospitals were soon closed. 

blocking health care for everyone

In 1912, Theodore Roosevelt proposed an innovative program that would have given all Americans across the nation access to health care. Although this would have greatly helped the Black communities, poor and rural white Americans would also have greatly benefitted from the program. Yet since so many southern conservatives subscribed to the deeply racist conclusion of Hoffman’s book, it became too significant a roadblock and Roosevelt would eventually give up. This started a long string of multiple universal health care initiatives in American history. 

The same fate befell Franklin Delano Roosevelt in 1942, when he initially planned for federally sponsored health insurance to be part of his Social Security proposal. Southern conservatives blocked it because they did not want Black Americans to get free health care.

“The South’s commitments to a hierarchical racial order,” Ira Katznelson explains in his book, ‘Fear Itself: The New Deal and the Origins of Our Time,’ “affected the full range of New Deal policies and accomplishments.”

Harry Truman also tried in 1947 for universal health care but faced the same staunch opposition rooted in racial biases. He too gave up, and later would call it the greatest disappointment of his presidency. Although, to his credit, he was able to get federal grants for the construction of hospitals in needy communities. Yet the former Confederate states used the money to build hospitals in white communities. None of them built a hospital in a needy Black community. Furthermore, they allowed the hospitals that were built to have enforceable policies of segregation. 

Progressive political commentator Thomm Hartman said that in the 1960s, under Johnson’s New Deal, Medicare was also nearly scrapped for the same racist reasons. However, the authors figured out a way to allow mostly whites to use it. The authors created a 20% gap so that you had to pay 20% of your hospital bill and doctor bill, which they believed would discourage Black Americans from using the program. Since so many in the South were suffering under Jim Crow and mired in poverty, many didn’t avail themselves. The fact that poor white families couldn’t access it either was a price they were willing to pay. Racism costs everyone. 

Many Black Americans also couldn’t get access to medical insurance since it was employer-based. “They were denied most of the jobs that offered coverage,” says David Barton Smith, an emeritus historian of health care policy at Temple University. “And even when some of them got health insurance, as the Pullman porters did, they couldn’t make use of white facilities.”

As a result, Black communities initiated their own health systems. Lay Black women spearheaded a national community health care movement, advocating for health facilities and education programs on nutrition, sanitation, and disease prevention. Black doctors and nurses, almost all of them trained in the only two Black medical colleges, Meharry and Howard, fought against this medical apartheid and advocated for a federal health care system.

Martin Luther King, Jr. talks with President Lyndon B. Johnson 

In 1961, when the American Medical Association tried to fight Lyndon Johnson’s plan for Medicare, they enlisted actor Ronald Reagan to make record albums that they could distribute which called Medicare a communist plot. Yet this time, proponents crafted a much more effective counter-message that health care was a fundamental human right.

Dr. Martin Luther King Jr. strongly spoke in favor of Medicare: “Of all the inequalities that exist, the injustice in health care is the most shocking and inhuman.” Medicare did pass, and became one of the most successful and consequential programs in American history. 

For the first time, Black Americans had access to a federal program for health care, as Medicare and Medicaid were not only applied to all Americans but also required the end of legal segregation of hospitals. However, LBJ had to make several concessions to get these programs past several southern conservative politicians. For one thing, domestic and farm labor were excluded, which were jobs primarily held by Black Americans. This had the desired impact of ensuring that most of them were denied access. Furthermore, LBJ had to agree that eligibility, benefit levels, and administration of these programs would be left to the states, which allowed them to discriminate even further.

the fight continues

Today the fight continues. While the Affordable Care Act expanded coverage to all but 10 states, resistance to Medicaid expansion in former Confederate states maintains racial health care disparities. White southerners who need health care keep electing politicians who won’t expand coverage. Historian John Bracey was blunt: “The poorest states in the Union are turning down expansions of Medicaid because a black person was offering it to them.” 

White and non-white Americans across the nation could have been guaranteed a fundamental level of care a long time ago without having to go bankrupt. We are the only industrialized nation on the planet that has medical debt. Our primary means of funding care are now GoFundMe campaigns, which beg for money from strangers. We could have been so much better off, but racism has a high cost for everyone—and not just those intended to be harmed.

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