Black History: Why A Political Economy of Healthcare Cannot Ignore Race & Racism

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Photo from 2011 – I still recommend these books for #BlackHistoryMonth!

As a health geographer, it is a given that place matters. Where you are born, where you live, where you work… these all shape our health and well-being, as well as our healthcare access. However, my background as a history student compels me to emphasize the importance of the histories of these places. Segregation was (and is) an essentially spatial management of racialized bodies and communities. In the U.S. residential segregation remains a reality, even after de jure segregation was ostensibly made illegal. Discriminatory bank lending practices, informal agreements among suburban residents post-white flight, and federal and state policies aimed at helping homeowners that disproportionately benefit white homeowners… these all shape the opportunities available to racially “othered” groups. For example, deindustrialization, the movement of jobs to neighboring suburbs, and hospital closures (esp. after the desegregation of hospitals) all converged to leave Black residents in larger cities in neighborhoods with lower jobs-to-residents ratios, more poorly-funded public schools, and fewer healthcare facilities in proximity. The result is that unemployment is higher, education quality is lesser, and those who do work are typically commuting longer distances to work, which exacts a higher temporal cost on top of the wage disparities these workers may already face.

“Political economy” is more defined broadly as social scientific inquiry into relationships between people and society. When I say “political economy,” I refer to Anthony Giddens’ Theory of Structuration, wherein the self/identity is situated within a broader (“macro”) social order and social reproduction. In other words, the “micro” cannot be understood without the “macro.” For example, how I understand myself as a cisgender Black woman who is disabled is also contingent upon the ways in which I am racialized, gendered, and medicalized, as well as my class status and relative access to healthcare which confirms my status as “disabled.” My embodiment at the intersections of race, class, disability, and gender are all contingent upon the ways in which social categories (enforced to the end of social reproduction).

In the case of healthcare, we have to begin by understanding healthcare providers as actors whose knowledge production is shaped by medical and scientific discourses and practices that include racial science, eugenics (reform eugenics includes the redefinition of race-as-biology via genomics**), and the history of medical researchers and institutions simultaneously excluding marginalized populations from care while exploiting them in their studies.

In spatial terms, we can think of healthcare providers as actors whose location decisions are shaped by federal and state legislation pertaining to their scope of practice and insurance reimbursements for their services, as well as locations of clinical programs themselves. Also important is how these healthcare providers are racialized. Why? The American Medical Association prohibited Black physicians from joining their ranks, and this membership was important in determining physicians’ admitting privileges. This, in turn, meant that Black patients of Black physicians were doubly excluded from better-resourced hospitals that catered to white patients in the context of de jure segregation.

The below linked article discusses the Simkins vs. Cone (1963) case that ended racial prohibitions on membership to medical professional organizations, which opened the door to desegregating hospitals.

AAIHS | (4 Feb 2017) Civil Rights and Healthcare: Remembering Simkins v. Cone (1963)

“In 1962, dentist George Simkins, Jr. unsuccessfully attempted to admit a patient to Moses H. Cone Memorial Hospital, one of two private white hospitals in the city supported by tax dollars. Combining his role as community dentist and President of the Greensboro chapter of the NAACP, Simkins initiated a class-action lawsuit against both Moses Cone and Wesley Long Community Hospitals. The NAACP’s Legal Defense Fund assisted in litigating the test case. Not only were African American patients barred from these institutions, Black physicians were barred from practicing there, even as both institutions received state and federal funds provided by the 1946 Hill-Burton Hospital Survey and Construction Act. Hill-Burton emerged from President Harry Truman’s failed healthcare reform and promised to rebuild and modernize the U.S. healthcare infrastructure. However, this program included a loophole where states that engaged in de jure racial segregation could use the money to build segregated facilities. Cone and Long Hospitals both benefited from this program and its segregation loophole. This is not to say that segregated hospitals did not exist before the Hill-Burton Program, however; historian Vanessa Gamble chronicles the movement to establish Black hospitals from 1920–1945.

Initially, the district court of North Carolina sided with the defendant hospitals; however, the Fourth Circuit Court of Appeals (and later the United States Supreme Court, which refused to hear the case) deemed that the two hospitals’ policies of racial discrimination for both patient admissions and visiting physician staff privileges violated the fifth and fourteenth amendments of the Constitution.”

and

“Though the Simkins case is lauded for bringing about a swift end to segregation in healthcare, among other things, it led to the decline of Black community hospitals. While some, like Grady Memorial in Atlanta, successfully negotiated the new terrain of race relations, federal monies, power, and increased opportunities for Black medical students and doctors elsewhere, others like Homer G. Phillips Hospital of St. Louis and L. Richardson Hospital shuddered under the burden of increasing medical costs, lack of staff, and changing ideas around the importance of these institutions. In effect, Black hospitals were an anachronism in the post-Simkins era. Where some Black patients could, like my grandmother, walk to and from their community hospitals, such an action is almost inconceivable today given the large, distant campuses of many contemporary urban hospitals and medical centers.”

 

Relatedly, we can link southern states’ refusal to expand Medicaid under the Affordable Care Act (ACA) with their antebellum tax regimes. Currently, Alabama, Georgia, Florida, Kansas, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee and Virginia have not expanded Medicaid.

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Kaiser Family Foundation – Geovisualization of Medicaid Expansion

In the case of Alabama, its tax base was destroyed by Emancipation in 1865, because they taxed by the number of slaves owned, rather than taxing land values (oh, because enslaved Africans were PROPERTY/CHATTEL). During and after Reconstruction, attempts to tax land and other forms of property were resisted, such that the state could not generate tax revenue to cover its service provision.

Why does this matter for Medicaid? Medicaid, administered at the state level, is about 50-50 federal and state funded- that is, the federal government matches state contributions of Medicaid programs.* Medicaid’s costs are higher when unemployment is highest and tax revenues are lowest, so even the federal contribution is not sufficient incentive. Unfortunately, these states are largely in the Black Belt, where poverty is concentrated and health disparities by race and class are notable.

South Union Street | (4 Feb 2017) A Permanent Wound: How the Slave Tax Warped Alabama Finances

“Like slavery, the slave tax would leave a permanent wound on the state. When slavery died, so did the tax. Reconstruction-era efforts to replace the lost revenue with increased property taxes — the only major source left — sparked an angry reaction. Legislators rushed to introduce tax restrictions after Reconstruction without making serious efforts to find other sources of revenue.

“That set in place decades-long policies that, to this day, make it difficult and sometimes impossible for Alabama to generate enough revenue to pay for its state services.The $1.8 billion General Fund, which pays for most noneducation services in the state, should grow no more than $25 million in 2018; the state’s Medicaid agency alone has requested a $44 million increase for the year.”

 

* For an overview of how Medicaid is funded, check out the Kaiser Family Foundation’s Issue Brief entitled, “Medicaid Financing: How Does it Work and What are the Implications?” (accessed 5 Feb 2017)

**On the topic of reform eugenics and the redefinition of race-as-biology via genomics, I recommend Sociologist and Legal Scholar Dorothy Roberts’ book, “Fatal Invention: How Science, Politics, and Big Business Re-Create Race in the 21st Century

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