Governor, Will You Stand in the Clinic Door?

This post was written by Sanjeev K. Sriram, MD, MPH, NPA member and Washington DC area pediatrician, it was originally published on his blog DR .in D.C. on July 10, 2012.  Follow him on twitter at @DrSriram
“Segregation now, segregation tomorrow, segregation forever!” George Wallace said this now infamous line on January 14, 1963 to thunderous applause at his inaugural address when he became Governor of Alabama.  Wallace won the election because of his defiant views towards the federal government’s efforts at racial integration, including the Supreme Court’s unanimous decision in 1954 regarding Brown vs. Board of Education, that made segregation unconstitutional.  Almost fifty years after Wallace’s speech, we once again find governors putting politics before civil rights.  In Texas, Florida, Louisiana, South Carolina, and many other states, governors have declared their defiance of the Affordable Care Act, which seeks to extend the basic human right of health care to millions of poor, working-class Americans, many of whom belong to minority communities.
Governor Rick Perry of Texas, Governor Nikki Haley of South Carolina, Governor Bobby Jindal of Louisiana, Governor Rick Scott of Florida, and Governor Scott Walker of Wisconsin have all issued statements and made speeches against the Supreme Court’s upholding of the Affordable Care Act.  They are perpetuating misinformation about the health reform law, but what is more dangerous is the fidelity these governors have for misinterpretations of “states’ rights,” like their predecessors from the 1950’s and 1960’s.  This ideology contributes to inequities in our current health care system, and we are morally overdue in establishing health justice for all.
With the recent Supreme Court decision to uphold the Affordable Care Act, we can begin to remedy some health disparities among low-income and minority Americans.  Currently, African Americans are twice as likely as whites to lack health insurance, and Latino Americans are three times as likely to be uninsured.  If the Affordable Care Act is fully implemented, the rates of uninsurance are expected to drop from 22% to 10% for blacks, and from 33% to 21% for Latinos, according to the projections of a study done by the Urban Institute and published in Health Affairs this past May.
To be clear, much of this progress will depend on the expansion of Medicaid eligibility in 2014, and this is where leadership (or lack thereof) at the state level will matter.  The Affordable Care Act seeks to expand Medicaid to include individuals and families earning up to 133% of the federal poverty level (that’s $14,500 a year for an individual, and $30,000 a year for a family of four).  But, according to the recent Supreme Court decision, the federal government is now not allowed to force states to expand Medicaid.  If a state wants to continue restricting access to Medicaid to families making less than, say, $7,000 a year, (which is Virginia state policy), then the federal government must follow the previous rules on funding that state’s Medicaid program.
However, if a state opts to participate in the Affordable Care Act’s expansion of Medicaid in 2014, then the federal government will provide 100% of funding for the state’s Medicaid program for the first 3 years, then 90% of funding every year after that.  Many health policy analysts have argued that states will take the deal, which is too good to refuse in light of rising uncompensated health care costs.  While I see reason to share in this optimism, there is plenty of evidence from the current condition of the uninsured that should make advocates cautious and vigilant.
Sadly, under the current federal-state partnerships on Medicaid, many states are falling short when it comes to enrolling eligible patients and families.  Of the 8 million uninsured children in our country today, almost 2/3 of them are eligible for Medicaid but are not enrolled in the program because states either fail to reach out to the families and/or states make the enrollment process unnecessarily difficult.   The Affordable Care Act seeks to rectify these issues, but states are not obligated to cooperate.
Indeed, where a child lives can impact his/her access to health insurance.  In six states (Maine, New Hampshire, Vermont, Massachusetts, Wisconsin, and Hawaii), the uninsured rate for children is 5% or less.  That rate increases to 15% or more in four states:  Florida, Texas, New Mexico, and Nevada.  Over a third of all of our country’s uninsured children live in just five states:  New York, Georgia, Florida, Texas, and California.  Most of these variations in coverage can be attributed to how state policymakers use (or misuse) their “states’ rights” to determine which families qualify for Medicaid/CHIP and how they are enrolled.
The disparities between states’ Medicaid eligibility standards and enrollment procedures plays a part in the disparities in uninsurance between different ethnic groups.  With over half of all American children now being born to minority families, it is worth considering that 1 in 9 black children and 1 in 5 Latino children lack health insurance (that’s compared to 1 in 14 white children).
In June 1963, six months after Governor Wallace promised to defy federal policies and to keep Alabama segregated, he physically stood in a doorway at the University of Alabama to stop two qualified black students, James Hood and Vivian M. Jones, from enrolling.  This ugly episode of American history became known as the “Stand in the Schoolhouse Door.” Local law enforcement was unable to convince the Governor to step aside and allow the students to enter.  Resolution of this conflict ultimately required President Kennedy to federalize the Alabama National Guard, who ordered Wallace to step aside and allow the students to enroll.
I do not anticipate Governors Perry, Haley, Jindal, Scott, Walker, or others doing anything cruel like standing in the doorway of a community clinic, blocking eligible patients from entering.  Nonetheless, their political stance against the Affordable Care Act, and their apathy for the seriousness of health disparities, will deprive families of their right to the highest possible state of health.  The Affordable Care Act offers a starting point for building a better health care system, but real progress will depend on policymakers in every state abandoning the obsolete ideologies and misinterpretations of “states’ rights” held by their predecessors.  Real progress will require state and federal policymakers deploying their political will and resources to promoting a new age of health justice for all.