Policy & Progress article: The South, Integration and Medicaid Expansion

By Adam Linker, Policy Analyst for the NC Justice Center’s Health Access Coalition

Like many institutions across the Southern United States, hospitals were largely segregated in the 1960s. Some cities had separate hospitals for white physicians and patients and black physicians and patients. Other cities segregated hospitals by floor.

This began to change with the enactment of the Civil Rights Act in 1964 and the establishment of Medicare in 1965. The Civil Rights Act said that organizations receiving federal funds could not discriminate based on race. Health care facilities desperately needed Medicare because they were treating a large number of uninsured seniors. But to get the Medicare funds, the hospitals and other clinics had to integrate.

I’m reminded of this history today as states decide whether to accept Medicaid funds to provide health insurance to their low-income populations. Under the Affordable Care Act, or Obamacare as it is commonly called, middle-income families will get subsidies to purchase private health insurance plans. Most low-income families will automatically qualify for Medicaid. That was how the law was structured.

Then the United States Supreme Court, in its decision upholding the constitutionality of the law, said that states could reject Medicaid expansion, forego the federal funds, and leave their uninsured populations uncovered.

In the 1960s many hospitals in the South staunchly resisted integration. These health care facilities were denied Medicare funds even as other hospitals started to prosper with this new revenue stream. There was no policy reason to deny black patients access to white hospitals. In fact, standing against the federal policy hurt patients, strained providers, and damaged the reputations of recalcitrant regions of the country. But some still stood against integration even though it made no moral or economic sense.

Today we see many of the same states that resisted integration are blocking access to Medicaid for their most vulnerable citizens. And, again, the resistance makes no moral or economic sense. We know that expanding Medicaid, for example, would provide health insurance to more than 500,000 North Carolinians. It would boost the bottom line of many health care providers, especially rural hospitals and clinics. We know expanding Medicaid would save the state money over the first 10 years. And we know that in the first three years alone expanding Medicaid would create 25,000 new jobs in the state.

Despite these overwhelming benefits, Republican legislators in Raleigh, along with Gov. Pat McCrory, declared that North Carolina will not take any new federal money to provide health insurance to low-income citizens in our state. This decision does not have to be final. There is no deadline to expand Medicaid. It works just like Medicare in the 1960s: as long as hospitals refused to integrate they would miss another year of federal financing. Similarly, every year that North Carolina declines to expand Medicaid means we pass on billions of dollars of funding.

By refusing Medicaid money we inflict other wounds on our population as well. The American Academy of Actuaries says that premiums for all insurance plans will be at least two percent higher in states that do not expand Medicaid. More businesses will get penalized for not providing affordable coverage to employees in states that do not expand Medicaid. Racial minorities and recently returned veterans from Iraq and Afghanistan will continue to be uninsured at higher rates than the general population in states that do not expand Medicaid. And, in states like North Carolina that refuse expansion, the terrible health disparities that are largely driven by a lack of access to health care will persist.

We know that Republican governors in eight states are pushing for Medicaid expansion. It is likely, just as every hospital eventually integrated, that every state will relent on Medicaid. But, as Martin Luther King said in his last sermon, progress never rolls in on the wheels of inevitability. In the 1960s it took a fight to tear down the walls of racial segregation. Those of us who support Medicaid expansion can’t sit back, smug in the knowledge that history is on our side. We must work and organize and push every day to make sure the most vulnerable in North Carolina are protected.

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