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Abstract
Excerpted From: Sarah Somers and Jane Perkins, The Ongoing Racial Paradox of the Medicaid Program, 16 Journal of Health & Life Sciences Law 96 (2022) (91 Footnotes) (Full Document)
Medicaid is the single most important publicly funded health program for low-income and underserved people. Providing insurance coverage to over 75 million people, Medicaid coverage largely removes affordability from the access to care equation.
Medicaid's role flew under the radar for many years. When added as Title XIX to the Social Security Act in 1965, Medicaid went largely unnoticed by the public, overshadowed by the much more visible Medicare program for older adults. Inserted into the Act quietly (there is little discussion of the law in the Congressional Record accompanying its enactment), Title XIX borrowed both the programmatic structure and the stigma associated with “welfare” in the United States. It was a common assumption among those in the know that Medicare would expand to provide universal coverage, while Medicaid “was just another substandard state program for the poor that would fade away.” But rather than go away, Medicaid evolved. Over the years, Medicaid has extended significant health coverage and benefits to millions of people, including people of color. Yet, it has often perpetuated disparities and exclusions based on race.
This is the central paradox of Medicaid. It has “racism baked into the program” and yet, it has transformed opportunities for health care, decreased racialdisparities in coverage and access, and includes features that--with attention and creativity--can make significant contributions to addressing inequities in the health care system.
[. . .]
Racism shaped the Medicaid program. Yet, over its 55-year history, it has chipped away at disparities, particularly for African Americans. It has not only increased coverage but also expanded access to services and improved health outcomes. It also has significant but untapped potential to diminish these disparities and create progress toward greater health equity. The Medicaid expansion offers perhaps the most significant opportunity to make progress as abundant evidence has already shown its potential to improve health equity. The federal government has made improving data quality and standardizing data collection a high priority, which is essential to identifying disparities and targeting interventions to specific subsets of the population. Finally, while much study remains to be done, managed care has the potential to address disparities and may also prove to advance equity. Medicaid provides the tools and structure. With funding, creativity, and increased effort, it may realize its promise as a true tool to fight the impact of systemic racism.
SARAH SOMERS, JD, MPH is Managing Attorney of the National Health Law Program's (NHeLP) Chapel Hill, North Carolina office. Contact her via email at
<JANE PERKINS, JD, MPH is Legal Director of the National Health Law Program (NHeLP), leading the organization's efforts to ensure that health care protections are implemented nationally and at the state level as the law requires Contact her via email at
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