A Racial Equity Test for the Build Back Better Package

By Wade Henderson

Congress will face a test of its commitment to racial equity with the upcoming Build Back Better legislation this month. More than 600,000 uninsured African Americans with incomes below the poverty line are among the 2.2 million adults who have no access to affordable health coverage simply because they live in one of 12 states that have refused to take up the Affordable Care Act’s Medicaid expansion. Closing the Medicaid coverage gap is essential to remedy this racial health inequity.

It has been over a decade since the passage of the Affordable Care Act. Of the 12 remaining states that have stubbornly declined to expand coverage to adults with low incomes, eight are in the South: Alabama, Florida, Georgia, Mississippi, North Carolina, South Carolina, Tennessee, and Texas.

Fully 60 percent of those in the coverage gap in 2019 were people of color, even though people of color represent just 41 percent of the adult population of the 12 states. Most live in Florida, Georgia, or Texas; more than 100,000 African Americans in each state fall into the coverage gap. In Alabama, Mississippi, North Carolina, and South Carolina, a majority of those without a pathway to coverage are African American. In Texas, more than half of those in the coverage gap — 422,000 people — are Latinos.

Who are the people in the coverage gap? They are parents, often with young children. They are working people. Many are essential workers who have kept our nation going during the pandemic by working in grocery stores and health care jobs. Yet they have no health coverage and no way to get it.

By closing the Medicaid coverage gap, Congress can improve the financial security of African Americans and Latinos as well as their health. Medicaid expansion is a powerful tool against financial hardship and bankruptcy because it prevents catastrophic out-of-pocket medical costs. Providing this safeguard is particularly critical for African Americans, given the substantial racial wealth gap.

Closing the Medicaid gap will also help address the Black maternal health crisis. States that expanded Medicaid have seen improved access to preconception and prenatal services that make pregnancy and birth safer for parents and babies. Medicaid expansion is associated with reduced rates of maternal death, particularly for Black women. Yet 235,000 Black women of reproductive age with incomes below the poverty line remained uninsured in 2019 without any pathway to affordable health coverage. Almost all of them live in the Southern states that have refused to expand Medicaid.

The bottom line: Congress, both Democrats and Republicans, must not leave hundreds of thousands of uninsured African Americans, Latinos, and other low-income people behind as it finalizes the Build Back Better legislation. This is one of several other pieces of legislation, including voting rights, which will test the commitment of members of Congress to take concrete steps to overcome the racial inequities and systemic racism which people of color have lived with and suffered from for too long.

People in the coverage gap have waited years for their states to act, and their states have failed them. They have weathered a pandemic that amplified pre-existing inequities in health care, with often deadly consequences for the Black community and other communities of color. It is time for a long-term, comprehensive federal solution that closes the Medicaid gap once and for all.

Wade Henderson is the interim president and CEO at The Leadership Conference on Civil and Human Rights.