Here are the materials you need to give a presentation to your organization or group on racism and health and why we need a national improved Medicare for all healthcare system. This is meant to inform and stimulate discussion about this topic.

Find the presentation as a Google slideshow here. If you need it in power point format, contact margaretflowersmd@gmail.com.

Download a sample script here: racism-and-health-presentation-script

Find more information about the presentation including a list of articles that were used to create it in this guide: racism-and-health-presentation-guide

Presentation and sample script:

In this presentation, I will discuss some of the ways that racism targeting black people has been institutionalized in the healthcare system in the United States from the beginning and how it is manifested today. I will also describe features of a national improved Medicare for all (aka single payer) healthcare system that would serve to ameliorate some of the disparities in health outcomes between black and white people and what more needs to be done to end the impacts of racism on health.

 

 

This presentation focuses on racism as it impacts black people, but discrimination exists in the treatment of all non-white people based on their race, ethnicity and country of origin. For example, in the United States, there is a long history of racism against Native American people that continues today. Native American people have worse health outcomes and a lower life expectancy than black people in the United States. 

 

 

There have been efforts to achieve a universal national healthcare system for more than 100 years but every attempt has been blocked. For example, the original Social Security Act included all workers but the Southern Democrats in Congress changed it to exclude agricultural and domestic workers, which meant about 60% of African American workers. Another tactic the Southern Democrats used was the “Southern Strategy,” giving control over welfare programs to the states so they had the power to discriminate. In 1965, Wilbur Mills, a powerful Dixiecrat and head of the House Ways and Means Committee, prevented health reform that could have potentially evolved into a national health insurance by making it a “three layer cake.” Instead of one health program, Medicare was created as a federal program for people 65 years of age and older with two parts, Part A for hospital coverage and Part B for outpatient coverage, and Medicaid was created as a state program for the poor. This fragmented system could not be unified.

Now we will look at some of the specific ways that racism is embedded in the healthcare system and impacts the health of black people. 

 

 

 

Early medical theory in the United States taught that being black was a disease that needed to be cured. Then it taught that human races were different species. It took until 1999 to end this belief when the Human Genome Project concluded that race has no genetic basis. Differences in health outcomes based on race are not due to biology but are due to systemic differences in access to health care and the environment in which people live. For example, in the general population, black people have a lower life expectancy and are two to three times more likely to die of heart disease than white people. Black veterans in the VHA have a lower death rate and less heart disease than white veterans. In the VHA system, a type of single payer healthcare system, all people have the same access to care and it is provided for free.

Now, imagine if everyone in the United States had equal access to health care and equal risk of dying. If black and white people had the same death rate, almost 100,000 fewer black people would die each year. Black people are sicker and die younger than white people even when they have similar education and wealth status.The COVID-19 pandemic is a stark demonstration of racial health disparities.It is disproportionately impacting black people with higher incidence of infection, more serious disease and higher death rates. Racial disparities in death rates are found throughout life. Black babies are more than two times as likely to die in infancy as white babies. Black mothers are three to four times more likely to die during pregnancy and childbirth as white mothers. Black children with asthma are five times more likely to die as white children. And black adults with a variety of cancers are more likely to die than white adults with the same cancers. We have to ask ourselves – what is it about our society and healthcare system that creates these disparities? 

At the beginning, during the era of chattel slavery, Africans were treated as property and not as human beings. European-style medicine treated slaves like it would treat animals, only focused on keeping them healthy enough to be sold and to work. Medical research in the US also treated black people differently and in horrific and unethical ways. The “Father of Gynecological Surgery,” James Marion Sims, developed his techniques through experimentation on enslaved black women in the mid 19th century without using anesthesia. In the mid 20th century, the Tuskegee syphilis experiments, in which black men were not told they had syphilis and were not treated for it, were conducted until they got public attention in the early 1970s and were forced to stop. Distrust of the medical system and medical research by black people continues to this day.

Distrust may exist because racial bias is still deeply ingrained in the healthcare system. Patients experience this bias when they come into contact with the healthcare system. This bias is part of the ‘Culture of Medicine’ that medical students and doctors are trained to operate within. The ‘medical gaze’ is the term for how physicians view their patients. It reflects the biases that exist in the culture including racial stereotypes. For example, in one study, physicians were given descriptions of patients and asked to make a diagnosis. When the patient was identified as black, the physicians were more likely to “ascribe violence, suspiciousness, and dangerousness” to them than for the exact same description in which the patient was described as white. On top of that, protocols for determining treatment for patients often include race as a factor. These protocols are designed so that race disadvantages black patients resulting in less or lower quality of care. In the culture of medicine, doctors who work in underserved communities are often viewed as “heroes” for doing so without questioning why there are underserved areas. This feeds the idea that inequality in healthcare is a given rather than something that is outrageous, shouldn’t exist and needs to end.

A new report found when black infants are cared for by black doctors, they are roughly 40 to 60% less likely to die. But, there is a deficit of black doctors in the United States. Black people who are interested in medical professions are more likely to become nurses than doctors. When white and black physicians are compared today, white male doctors are more likely to be specialists and surgeons than black male doctors. When adjusted for other factors such as hours worked and specialty, white male doctors earn much more than black male doctors. Incomes for white and black female doctors are similar although substantially lower than male physicians and have been stagnant while income for male physicians has risen over time. 

 

Hospitals are closing down at a rate of about 30 per year. Rural hospitals are hardest hit. Since 2010, 120 rural hospitals have closed. The highest number of closures are occurring in the 17 states (many of them in the South) that did not expand Medicaid under the Affordable Care Act. In small towns, local hospitals can be the largest institution, which means it is the largest source of jobs. Losing a hospital also means losing investment in that community. Businesses consider health care when deciding where to locate. Rural hospitals that are at risk for closure tend to be in areas that have a higher population of black people, higher unemployment and greater health needs than in areas where hospitals are financially secure. Urban hospitals are also closing particularly in areas that are being gentrified, which tend to be black and poor communities. In this situation, it becomes more profitable to convert the hospital to condominiums, retail or business use. 

Access to care is also limited because the percentage of black people without health insurance (9.7%) is almost two times higher than white people without health insurance (5.4%). But access to care is not the most important driver of good health. The biggest factors are the social determinants such as wealth, education, housing, the environment, stress and more. Systemic racism has created conditions that worsen social determinants, and thus health outcomes, for black people. The wealth gap has gotten wider over the past few decades. From 1983 to 2013, the median wealth of black households fell 75% while the median wealth of white households rose by 14%. Note the large disparity: black households have a median wealth of $1,700 and white households have a median wealth of $116,800. One reason is home ownership, an asset that is often passed down through generations. Home ownership by black people has fallen to just above 40% while 70% of white people own homes. Education is also important. Black students are more likely to attend a high poverty school (6 out of 10) than white students (1 out of 10). The results are lower standardized test scores in black students, thus limiting their opportunities. Another factor that impacts health is stress. Black people in the United States face racism everyday as they attend school or work or go about their daily activities. Black people have more stressors than white people even when factors such as wealth and education are removed.

Now that we’ve looked at some of the aspects of racism and health, let’s discuss changes to our healthcare system that could decrease racial disparities in health. Specifically, we’ll look at how a National Improved Medicare for All system could do that. National Improved Medicare for All is a system in which every person living in the United States would have healthcare through a national, publicly-financed healthcare system that is lifelong, covers all necessary care and is paid for through taxes.It is called Medicare because it is similar to our national Medicare system, but better because it covers more and there are no out of pocket costs.

 

In a National Improved Medicare for All healthcare system, every person in the United States would have a Medicare card from birth to death. The fear and hassle of losing health insurance when a person changes jobs or moves would end. The program would cover all medically-necessary care. This includes care that is currently often not covered such as mental health, dental care, vision and hearing, all medications and medical equipment and substance abuse treatment, rehabilitation and long term care. Every person would have the same coverage just as veterans do in the Veterans Health Administration.

 

In a national improved Medicare for all healthcare system, all health professionals would be part of the system and patients can choose where to seek care whether they are at home or traveling. Health insurance networks that dictate where patients can be seen would end.This also means that if a person needs to be seen at a specialty center out of state, they are covered. Discrimination in health care would be illegal and there would be a way for people to report it if they are mistreated by the healthcare system. Another benefit of national Improved Medicare for all is that all hospitals and health facilities would be funded by the government and so they would be financially secure and not at risk of closure.

 

Under national improved Medicare for all, the system would be paid for through taxes based on income or ability to pay. There would not be any costs when patients seek services. Health professionals and facilities would bill the government and not the patient. This would remove the financial barriers to care that currently exist for both uninsured and insured people. In the United States, people delay seeking care or getting treatments or prescriptions because they do not have the cash or have to choose between paying for health care or other necessities such as rent or food. It would also end personal bankruptcies due to medical illness. This is the most common reason for personal bankruptcy in the United States, impacting about 500,000 families each year. This would be an important step in reducing the wealth gap between black and white people by relieving the burden of healthcare costs and reducing personal bankruptcy and loss of homes.

When governments are responsible for paying for the health care for their people, it changes public policy priorities to include impacts on health. It also incentivizes governments to take a more preventative approach to health. This is evident in nations with universal public healthcare systems around the world. In the United States, polluting industries disproportionately impact black communities. Once the government is fully liable for the cancers or long term impacts of disease caused by pollution, it will be less likely to allow this in places where people live. The same with toxic consumer products and pesticides in our foods. Countries with high rates of diseases due to lack of exercise have built more bike and pedestrian friendly areas to encourage physical exercise. Countries that treat health care as a public good also have a stronger safety net because they understand that social determinants such as access to affordable housing, high quality education, jobs with living wages and pensions are also necessary for good health and well being. Moving to a national improved Medicare for all healthcare system will be a sea change in the United States that could drive the demand for stronger public systems that meet our basic rights and necessities as human beings.

Moving to a national improved medicare for all where everyone has access to the health care they need throughout their life is a simple first step to start addressing the current healthcare crisis but as we now know, the problem of racism in health care and systemic racism that drives inequality is long term and deeply ingrained. Here are some other actions that are also necessary and should be next steps. Many wealthy countries provide free medical education. This would help address racial disparities in health professionals, but beyond that, more could be done to support black people from a young age who are interested in medical fields. National improved Medicare for all would provide operating funds to hospitals and other health facilities. Communities must demand that they have the resources they need to access care in a timely way. Medical bias in health care delivery must be deliberately addressed both in medical education and in medical institutions. It must be removed from treatment algorithms and protocols. One way to reduce racially-biased practices is to give communities greater control over their local healthcare institutions including how the budget is used, who is hired and fired and what services are provided. What would you add to this list?