Our society is plagued by the chronic pandemic of institutionalized racism, and healthcare is no exception. As a medical student involved with research, I analyze in-depth interviews of majority Black mothers with low incomes to identify barriers to care during and after pregnancy. I am deeply troubled when I hear the personal stories of mothers who routinely cannot access basic medical care after giving birth to their children, because they no longer have health insurance. I am disheartened by patients’ justified distrust and withdrawal from a system that is inherently not designed to serve them.
At the start of medical school, I took an oath to “confront historical traumas and systemic injustices that continue to impact people’s lives, especially those perpetuated by the institution of medicine.” Yet, while other medical students and I have provided free health screenings at local grocery stores and helped provide care through our free student-run clinic, this is not enough. There must be systemic, sustainable change that ensures people receive equitable care, even if these safety-net, volunteer-based programs were to disappear.
A step I have taken along with other fellow classmates is to create LouHealth, a public health and policy advocacy group that aims to promote health equity, especially during a pandemic that has placed stresses on an already broken system. Similarly, as a society, we have the civic duty to vote for the promotion of health equity in our communities.
To take an important step in combating injustice, we must pass Missouri Medicaid Expansion on August 4, which is projected to cover 270,000 Missourians making under 138% of the poverty line ($36,156 for a family of four). While all low-income Missourians suffer the effects of classism when attempting to access care, the poverty rate of Black households is more than double that of white households. The existence of such disparities, largely attributable to a legacy of discrimination in housing, education, and employment, makes programs like Medicaid vital to building health equity. A recent study found that in states that expanded Medicaid, racial inequalities in coverage decreased by 23%, while another found substantial decreases in deaths for both minorities and low-income individuals.
Currently, most mothers on Missouri Medicaid—particularly those who are Black—lose Medicaid coverage shortly after giving birth. While unexpanded Medicaid does not cover non-disabled adults without children, it does cover pregnant women with incomes below about $52,000/year for a family of four. However, 60 days after giving birth, this threshold for Medicaid qualification drops to include only parents who make under $5,500/year for a family of four, ripping healthcare away from women after the physical trauma of giving birth.
According to the Missouri Foundation for Health, 76% of Black women in Missouri who had a live birth were on Medicaid, almost twice that of white women, disproportionately leaving low-income, Black women at risk for losing healthcare after giving birth. Black women with low incomes face these injustices in the context of the multiplicative effects of racism, sexism, and classism and thus are particularly vulnerable to health inequities perpetuated by unexpanded Medicaid.
Our current system tells women that the only time their health needs matter is during pregnancy. This heinous oversight further perpetuates the glaring health disparities faced by Black women in Missouri. Maternal mortality (deaths related to pregnancy within one year of delivery) is nearly three times as high for Black women compared to white women in Missouri, according to a Washington University brief.
Racial disparities in maternal mortality exist for Black women regardless of income; however, without Medicaid expansion, Black women with lower incomes cannot get the long-term care needed before and after pregnancy to prevent and manage chronic diseases that contribute to their higher maternal mortality risk. These include hypertension, diabetes, and heart disease, which are already more prevalent in this population, with increasing evidence that trauma related to experiencing racism contributes to these adverse health outcomes.
These women need persistent monitoring for these chronic diseases, and Medicaid expansion will provide this necessary access to longitudinal healthcare after pregnancy. However, the current system leads to a preventable loss of Black lives.
On August 4, we can take a stand to improve healthcare access for low-income, Black women. While these women are among many who will benefit from Medicaid expansion, the healthcare system has historically failed Black women. On August 4, we can vote to begin dismantling systems that have disproportionately devastated economically disadvantaged Black communities in Missouri.
Personally, I will continue working to uphold the oath I took at the start of medical school—through advocating for change, highlighting voices in our community, and sharing knowledge. While a substantial amount of work remains, expanding Medicaid is a step in the right direction.
More information about Missouri Amendment 2, the Medicaid Expansion Initiative, can be found at https://tinyurl.com/Medicaid-ballot.
Drishti Sinha is a second-year medical student at the Washington University School of Medicine in St. Louis and a co-founder of LouHealth, a student-led, policy and public health advocacy response to COVID-19.