Medicare for All

Just this Monday, we celebrated Martin Luther King Day, a tribute to one of the great leaders of the movement for racial justice – but something that often gets forgotten in the flurry of MLK quotes that become memes this time of year is that equity in healthcare was a crucial part of King’s vision. Throughout his career in activism, he often stated his conviction that “Of all the forms of inequality, injustice in healthcare is the most shocking and inhuman.” Sadly, over 50 years after his death, racial inequity in healthcare is even more shocking and inhuman. Today, we’re joined by public health expert Walter Tsou to do a deep dive into the horrifying world of racial health injustice, how we got here, and how we make real change.

The show is joined on MLK Day by Dr. Walter Tsou – past president of the American Public Health Association and former health commissioner of Philadelphia! Gillian asks how Walter dedicated his life to health access and health equity. When Walter graduated from med school he stumbled into a job at a public health clinic in West Philadelphia that treated patients lacking private insurance or the money to afford medications, which gave him his first window into the deep economic, racial, and health divides in the U.S. This launched his career in public health advocacy.

Walter served as the Health Commissioner of Philadelphia from 2000 – 2002, and to him the most stark racial inequity he had to deal with was the gap in infant mortality – black infants at that time were 2.5 to 3 times as likely to die before reaching age 1 than white infants. Walter looked up the most recent statistics in preparation for the podcast, and the number had barely changed. The traditional way that states are pretending to do something about infant mortality is to create an Office of Equity contained inside their Department of Health that has maybe two staff people. To make a real difference in infant mortality, Walter says, you have to tackle the largest social determinants of health – education, job opportunities, housing, transportation, and so on. Two or four people in an Equity Office aren’t going to make a difference – it’s window dressing.

On top of this, Walter says, the U.S. has abandoned most of its community health work, which was widespread under LBJ’s Great Society programs after WWII, when community nurses would go into communities and address social determinants of health.

Gillian backs up to share some of the big-picture distressing findings from the Commonwealth Fund’s scorecard on racial equity in U.S. healthcare:

• Provisional life expectancy report released by the CDC in 2020 shows that Black and American Indian/Alaskan Native people live fewer years on average than white people (see data here)
• Black/AIAN individuals more susceptible to chronic diseases like diabetes, hypertension
• Higher rate of pregnancy related complications, higher infant mortality rate (see our episode on maternal health for more details)
• Poor healthcare outcomes are driven by higher poverty rates, higher-risk environments, less access to healthcare among communities of color
  • Less likely to have health insurance, more likely to incur medical debt, more cost-related barriers to care, less preventative care
• These unequal health outcomes persist across all states in the U.S.
• Black women are more likely to be diagnosed with breast cancer at later stages and to die from breast cancer than white women
• Uninsured rates are much higher in communities of color, particularly states that have not adopted Medicare expansion
• Black Medicare beneficiaries are more likely than white beneficiaries to be admitted to a hospital or to seek care in an emergency department for conditions typically manageable through good primary care
• Lower rates of vaccination – example – Black, AIAN, and Latinx/Hispanic adults are less likely than AANHPI and white adults to receive an annual flu shot

Walter highlights that the history of racism in U.S. healthcare, including the infamous Tuskegee syphilis experiment on black men, meant that when COVID struck, communities of color generally had less trust in the medical system and the opinions of medical experts, in addition to being more impacted by social determinants of health.

How would Medicare for All impact racial inequities in healthcare? It would be a huge step towards leveling the playing field, but it’s not a solution by itself – there is a huge concerted effort needed to guarantee equal access to health services, and M4A would also not in itself address social determinants of health (education, housing, environment, etc) that have such a profound impact on whether we get sick or injured in the first place. Ben points out that our current healthcare system is linked to the job market, where most people get their health insurance, and if you don’t get healthcare through your job then it’s linked to your access to money, to purchase insurance on your own. This means that any racism in the job market has an impact on your healthcare coverage, and any racism in access to money and financial security also impacts your healthcare coverage. Medicare for All would at the very least de-link your health coverage from these other systems, which are deeply marked by racial inequities.

Walter closes by talking about how the tide within the physician community is turning towards support for Medicare for All, as doctors face more and more barriers to treating patients. A younger generation of doctors is leading the charge within the American Medical Association and state medical associations.

Our podcast manager is Angelique Davis, our researcher for this episode was Sophia Simeone, and our audio editor was Christian Brandt!

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This show is a project of the Healthcare-NOW Education Fund! If you want to support our work, you can donate at our website, healthcare-now.org. It’s end-of-year giving season, and thanks to a generous matching gift from the United Steelworkers Union, every dollar you give will be doubled, so please make your way to our website and chip in!