State of the Dream 2014: Executive Summary


Of all the forms of inequality, injustice in health care is the most shocking and inhumane.
– Dr. King in a speech to the Medical Committee for Human Rights, 1966

Now is the time to lift our national policy from the quicksand of racial injustice to the solid rock of human dignity.
– Dr. King in Letter from a Birmingham Jail. 1963

The vast racial disparities in health outcomes, healthcare and health insurance are a reflection of larger structures of racial inequality that have persisted in the United States long after the civil rights victories of the 1960s. Undoing centuries of racial inequality is a long-term fight that will not be solved by any one law or policy change. However, there are fights underway right now in states across the nation–in particular, fights over implementation of the Patient Protection and Affordable Care Act (ACA, or "Obamacare")—that can move the long-term struggle for racial equality forward at a very basic, human level: health.

Although progress has been made on other fronts, vast disparities of wealth and income continue to exist along the lines of race. Black and Latino households have only 13 and 12 cents of net wealth respectively to every dollar that the median White household has. Black and Latino families earn 57 cents to every dollar that the median White family earns. Blacks and Latinos are more likely to be unemployed, even when taking education into account. In 2012, 6.3 percent of Black college graduates and 5.1 percent of Latino college graduates were unemployed, compared to only 3.7 percent of White college graduates.

Despite laws prohibiting housing discrimination, communities of color remain largely segregated from Whites. Poor Blacks and poor Latinos are significantly more likely than poor Whites to live in high-poverty neighborhoods. Living in such neighborhoods is a major contributor to the shorter life spans and significantly higher incidence of health problems faced by Blacks and Latinos. Lack of adequate healthcare facilities, healthful food, and green space to walk or jog, coupled with higher exposures to lead and other toxins, and the physical stress of caring for a family’s well-being amid high crime rates, poverty, and racism itself all take a heavy toll on one's health.

Making matters worse, Black and Latino families have long faced much greater hurdles in securing adequate health insurance. Our heavy dependence on employers to provide health insurance has simply worked to replicate the underlying racial disparities of the job market. Blacks and Latinos are more likely to work in low-wage, minimum wage,  temporary, contingent, and part-time jobs—sectors that typically provide little or no health benefits for employees. As of 2012, 29 percent of Latinos and 19 percent of Blacks lacked health insurance, compared to 11 percent of Whites.

The ACA, if fully implemented in all 50 states, presents an opportunity to significantly narrow the racial disparities in health insurance coverage. Through a combination of Medicaid expansion for those earning up to 138 percent of the federal poverty level, and health insurance exchanges for others, the ACA aims to cut the number of uninsured Americans in half, from 50 million to 25 million. Many of the 25 million who will remain uninsured are undocumented immigrants and recent immigrants who are excluded from benefits of the ACA as originally passed by Congress. Nonetheless, the ACA represents a significant expansion of coverage.

Blacks, Latinos, and other communities of color have the most to gain by expanded health insurance coverage and other initiatives contained within the ACA. In addition to expanding health insurance coverage, the ACA will expand healthcare access in low-income communities, increase the number of practitioners of color, and improve doctor-patient communications. Investments in outreach and education aim to ensure that all who are eligible know about their rights and the services available to them. Finally, the ACA ends exclusions for pre-existing conditions, lifetime coverage limits, and more.

Unfortunately, opponents of the ACA–mostly Republicans in Congress and in states across the nation–have been systematically challenging and disabling critical components of the healthcare law. . In October 2013, the Tea Party wing of the Republican Party went so far as to shut down the federal government in a failed attempt to dismantle the ACA. While the high-profile fight in Congress captured America's attention, the real damage to the ACA is happening at the state level.

In June 2012, the Supreme Court upheld the bulk of the ACA, but simultaneously made it easier for states to opt out of the Medicaid expansion provision, a key provision of the plan that aims to provide insurance to all Americans with incomes up to 138 percent of the federal poverty line, including millions of adults who do not get healthcare under the current Medicaid program. As of this writing, 25 states—all but three headed by Republican governors—have chosen not to expand their Medicaid programs in 2014 (two of those 25 states have waivers pending and plan to expand their Medicaid programs after 2014).

This new 25-state coverage gap will leave millions of Americans without health insurance while exacerbating racial disparities in health and healthcare. In particular:

  • Nearly 5 million people who would have otherwise been covered—disproportionately people of color—will now go without health insurance.

  • Whites represent 65 percent of the nation's population (excluding undocumented immigrants, who are ineligible for expanded coverage under the ACA) but account for just 47 percent of those who will fall through the new 25-state coverage gap.

  • Blacks make up 13 percent of the nation's population, but represent 27 percent of those who will fall through the 25-state coverage gap.

  • Latinos represent 15 percent of the nation's population (again, after excluding undocumented immigrants), but represent 21 percent of those who will now fall through the 25-state coverage gap.

Blacks are particularly impacted by the refusal of almost all Southern states to adopt the Medicaid expansion. The "Black Belt," a region of the country where Blacks make up a significant portion of the population that stretches from Virginia down to Georgia, and across to Louisiana and Arkansas, will be almost entirely left out of the ACA's Medicaid expansion because of the 25-state coverage gap. Latinos are also impacted, both by the original bill's exclusion of recent and undocumented immigrants from benefits of the plan, but also due to the 25-state coverage gap, including the decisions of Texas and Florida not to expand their Medicaid program under the ACA.

As this report makes clear, engaging in state-by-state fights over implementation of the ACA is an important step in closing the vast racial disparities in health insurance and healthcare. Doing so will also have ripple effects in terms of closing the racial wealth divide, as persistent health problems and medical debt are major contributors to wealth loss in communities of color. Most notably, these state-by-state fights are taking place now.

Pushing leaders in the remaining 25 states to fully implement the ACA by expanding their respective Medicaid programs is a critical first step to closing the racial disparities in health insurance, as is increasing resources for education and outreach so that all who qualify take that critical step of applying for benefits. There are plenty of good reasons for governors and state legislators to expand their Medicaid programs under the ACA, but to counter the political posturing, it will take strong organized movements demanding action now.

At the same time, we also hold out hope for bolder action in states that have already expanded their Medicaid programs, such as Vermont, which has leveraged the ACA's rules to establish the nation's first single-payer healthcare system, scheduled to come online in 2017. And as of this writing, the Vermont system–with the appropriate motto: Everybody in, nobody out–will also cover undocumented immigrants. Implementing such a bold healthcare plan in other states, including states with larger Black and Latino populations than Vermont's, would be a huge step forward–for people of color as well as low-income Whites.

As a society, we must also continue to challenge the concentrated poverty, racism, and related stresses that are the driving forces behind the vast racial disparities in health outcomes that we see. As such, we call on organizers and activists across the nation to continue the fights to rein in economic inequality, break up concentrated poverty and promote a more inclusive prosperity that elevates the well-being of all, particularly those who have been excluded in the past.

Strengthening public programs that raise the floor is not easy. History has shown that when public programs are perceived as providing significant benefits to people of color–as the ACA's Medicaid expansion would clearly do–these programs run the risk of becoming viewed as a "handout" due in part to the racist predispositions of some. This dynamic of racializing public programs was a significant contributor to the erosion of public programs and laws that once built the White middle class–FHA loans, GI Bill, the minimum wage, Social Security, and more. After the Civil Rights victories made it possible for Blacks to access those same programs, the assault on the governmental role in supporting average Americans, which now included Blacks, began in earnest.

However, history presents us with another important lesson: Whites, and particularly low and middle-income Whites, have also suffered as those public programs were dismantled. Attacking the public role in providing safety nets and ladders of opportunity to working Americans, for whatever reason, is a lose-lose proposition for both people of color and Whites. After decades of such assaults, we now face some of the highest levels of inequality the nation has seen since the late 1920s, wages are flat and declining, and Americans everywhere are suffering.

If we are to build a broad-based movement for economic justice, we must acknowledge the way in which racism has placed an unjust burden on entire groups of people, and from that shared point of understanding, build a broad-based, multi-racial movement for real justice that will not be vulnerable to such divide-and-conquer tactics.

It is our hope that this report both moves the debate over healthcare forward in a constructive way, while also giving organizers and activists across the nation the analysis and tools they need to build broad-based, multi-racial movements for greater equality. With those goals, this report is organized as follows:

The Report

  • Section 1 begins with a broad analysis of the historical and contemporary forces driving the vast racial disparities in income, wealth and opportunity. It is our belief that one cannot truly assess the current realities without a full grasp of the historic trends and patterns that created them.

  • Section 2, the heart and most timely aspect of this report, examines the contributors to disparate health outcomes and the current debate over implementation of the Patient Protection and Affordable Care Act (ACA or “Obamacare”), its implication on communities of color, and clear policy directions for moving forward.

Additional Resources

  • Section 3 presents a summary of the latest data about the racial divide, including disparities of income, wealth, poverty levels, unemployment rates, educational attainment, and more.

  • Section 4 offers a few examples of interactive exercises and curricula that organizers in unions, worker centers, religious congregations, and community organizations can use to stimulate discussion about the racial wealth divide.

Download the report (PDF)  |  Key Findings  |  Media Coverage & Overview

Related Infographics – Medicaid Opt-Out States  ...more to come!

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To read past State of the Dream reports–click here.