With the future of the Affordable Care Act uncertain under President Trump, many Americans are left worrying how they will manage without health care. The Americans who must shoulder this burden are disproportionately people of color. It should come as no surprise to those familiar with the history of health care in this country that once again, our system, purportedly built to protect and promote health, is systematically ignoring the right to health care for communities of color.

The very structure of modern medicine in this country is rooted in the supremacyof white physicians. This is unsurprising, given the larger context of the institutional racism that pervades our society as a legacy of slavery. The 1910 Flexner report, which many credit for the legitimization of the medical profession in the United States, closed all but two African-American medical colleges. While encouraging the integration of men and women students, the report accepted racial segregation in medical education and further suggested that physicians of color should be trained differently; namely, to humbly serve their people as sanitarians. Today, the majority white voice in medicine and medical education persists; the 2015 American Association of Medical Colleges diversity report demonstrates that only 3 percent of full-time medical school faculty identify as black or African-American.

The structural racism that pervades the medical profession extends beyond physicians to the people they serve. Patients of color, and African-American patients in particular, have been subjected to racism in their care for as long as physicians have served them. Takethe case of segregation of hospital admissions: when patients of color were relegated to separate and unequal hospital wards where they suffered from demonstrably worse outcomes than did their white peers.

In 1931, Ms. Juliette Derricotte, the Dean of Women at Fisk University, was critically injured in amotor vehicle accident. The closest hospital, nearby Hamilton Memorial Hospital in Dalton, Georgia, did not admit patients of color. After six hours of searching for a hospital that would accept her as a patient, a Chattanooga facility located 35 miles away agreed to care for Ms. Derricotte. She died in transport.

The injustice of racism in health care is further underscored when one acknowledges how physicians have systematically exploited patients of color for medical experimentation. White physician Thomas Hamiltonleft African-American slaves in burning-hot pits as he sought a cure for sunstroke. White researchers studied syphilis in black men in the Tuskegee Study, watching them die until 1972 27 years after penicillin was proven to bethe life-saving treatment of choice for the disease.A young black Henrietta Lacks cervical cancer cells were harvested by white physicians without her informed consent and became the first immortal cell line, used across the globe for scientific pursuit. And yet, the scientific gains from these and scores of other unethical studies remain less accessible to patients of color than to their white peers.

Since the 1930s, our nation has taken several steps toward the creation of a more equitable health care system. One of the boldest and most successful steps towards health equity on a federalscale waswhen Lyndon B. Johnson signed Medicaid and Medicare into law in 1965. These programs expanded health care access for the elderly and the poor, regardless of race. It also condemned hospital segregation and required hospitals to comply with Title VI of the Civil Rights Act in order to be certified. Before Medicare and Medicaid, wealthy patients received twice as much care as the poor. By 1977, poor patients received 14 percent more care than the wealthy. The reversalwas and remains much needed, as poor patients continue to suffer worse health outcomes at disproportionately higher rates.

The 2010 Affordable Care Act (ACA) represents another important, though insufficient, step toward health equity in the United States. Among its successes was the provision of coverage to many Americans of color. Of those gaining coverage from 2010 to 2015, 57 percent were patients of color. These patientsare disproportionately likely to live in poverty and qualify for Medicaid coverage, and systemic discrimination and marginalization maintain this status quo.

Should the ACA be repealed, 30 million people will become newly uninsured. This includes not only the 19.2 million individuals who gained coverage under the ACA, but an additional 11.8 million served by the individual insurance market, which would collapse after repeal.

The ACA largely accomplished this coverage growth through the expansion of Medicaid to all those earning less than 138 percent of the federal poverty level ($27,821 for a family of three in 2016). However, while expansion was intended to be nationwide, 19 states most of them Republican-led Southern states with histories of racial segregationhave opted out and Medicaid coverage in those states remains limited. The median income qualification for parents in many of the states not participating in expansion is just 44 percent of the poverty level, or $8,870 for a family of three. Childless adults remain unqualified.

Despite somesignificant achievements, the U.S. health care system remains unfair on multiple levels. First, people of color continue to experience inequitiesin health outcomes. Minority and low-income patients with breast and colorectal cancer are less likely to receive recommended treatments as compared to white patients. Black males have a life expectancy almost five years shorter than that of white males. Second, low-income communities including poor white people continue to bear a disproportionately high burden of the cost of their care under the ACA, facing skyrocketing deductibles ($3,064 in silver plans, and $5,764 in bronze plans) and unaffordablecopays. When one considers that half of Americans cannot afford an unplanned $400 expense, we must acknowledge that health care reform in this country has not gone far enough in erasing its clear history of racism and inequity.

Any health care system in our country will, to a certain extent, be burdened by institutional racism as a result of the legacy of slavery in the United States. Even so, research suggests that a single-payer system could radically reduce health inequity, even if biases persist. Single payer national health insurance would be a system in which a single public agency, rather than private insurance companies, provides health care financing whilethe provision of care remains largely with private institutions. The evidence to suggest how single-payer would help lessen racial inequity in health care comes in part from the Veterans Administration (VA), a quasi-single-payer system here in the United States, in which black patients actually fare better than white patients in multiple measures of health. In the same measures, black Americans outside of the VA system fare much worse.

While it may be comforting to simply defendour current health care system in this time of immense change under a Trump administration, it is important to remember its limits. We cannot ignore that the health inequitygap continued to rise under President Obama and that poor Americans and Americans of color have never been adequately protected by our system. Let us struggle not only against the policies that promise to take us back to greater and less equal American health system but also for a change that would promise true equity in health care for all Americans. If we want to improve health equity in our nation and fight for racial justice, the answer is a system that provides universal, equal health care for all.

Contributing Writer

Boston University School of Medicine

Armide Storey is medical student at Boston University School of Medicine. She is particularly interested in understanding health as it intersects with class, race, ability, sexuality, and gender.

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Medicine Has a Problem with Racism - in-Training