It's Only Five Dollars: Experiences with Race, Class, and Health
By Charlise Randall, MHSA
During my graduate studies in public health at the University of Michigan, I was acutely aware that I stood at an intersection between race and class that made me an outsider in almost every instance. I began to understand that those from my poor, Black childhood neighborhood and my new colleagues in a predominately white institution (PWI) had not fully seen nor understood the world of the other, and that I was stuck somewhere between not quite fitting in at home and not totally accepted by my college peers. On many occasions, I felt like I remained just out of earshot of the inner circle; someone whose presence was a feel-good symbol of progression but whose opinion was only minimally welcome. Of the more than 70 people in my cohort, 6 of us were Black, and almost none had come from a background like mine.
During my first year of the program, I was in a broad crash course overview of the U.S. healthcare system, which is unique among developed countries in not guaranteeing healthcare to all of its citizenry. We were required to do extensive reading before class, the professor would present on the material, then we would discuss in small groups different themes and thought-provoking questions. Typically, the discussions remained as surface level as our understanding of the content. The American healthcare system is an intricate toilet catching the compounded excrement produced by all other social systems; the more we learned, the less we knew and the less our solutions seemed comprehensive enough to combat problems that started much farther upstream from healthcare.
I sat in class everyday formally learning what I had already known and experienced: Black Americans have some of the worst health outcomes across the board from hypertension, to diabetes, to heart disease, to cancer. Of course, indigent Black people fare even worse. Our lives are lived sicker and shorter, our children are far more likely to die in their infancy, and our experience with the healthcare system is more hostile than our white counterparts.
On one particular day, we were covering Medicaid: the United States’ public insurance option for indigent people. After doing an overview of the program’s history, beneficiary demographics (disproportionately minority), funding sources, eligibility requirements, program variances between states, and what influence the Affordable Care Act (aka “Obamacare”) would have on the program, the professor touched on co-payments. He asked us to discuss in our groups whether or not Medicaid recipients should be subject to a $5 co-payment every time they go see a doctor to discourage frivolous use of services, a practice commonly used by insurance companies to control costs.
When the professor instructed us to discuss, one of my classmates quickly turned around and said “Of course they should. It's only five dollars.” His comment all but halted any further discussion on the matter in his group.
I knew this classmate fairly well. My mother had attended high school with his parents. He was a middle- to upper middle-class white male. While his parents had humble beginnings, he was proudly reaping the benefits of their upward mobility. He was intelligent, outspoken, and well-intentioned, but based on that statement and ones similar to it, grossly ill-informed.
I was not in his group so I did not reply to his comment. However, I thought very deeply about it. To him $5 was insignificant, but to someone poor enough to be on Medicaid, every penny is accounted for. I thought back to my mother sitting at a desk in our home not long before it was foreclosed in 2008. As I grabbed two quarters to buy snacks from a neighbor who sold them out of his home, her face said put it back, and I didn’t need an explanation. In my head, I began calculating the cost of five packs of ramen noodles, a loaf of white bread, a dozen eggs, and a few cans of tuna. I could feed two children with $5.
The discussion in my group took a much broader approach. We weighed the pros and cons of requiring co-payments and some potential unintended consequences. What if Medicaid recipients are waiting longer to go to the doctor and end up in a worse condition requiring a trip to the emergency room, a much more expensive healthcare encounter? How much excessive use of services even exists within the system and is it worth the risk to try and curtail it? Is $5 the right threshold amount to reduce use of services? Should it be $10? There was no consideration of who these people were, what they really needed, and the day-to-day impact something like an additional expense could have on their lives.
When the professor corralled the groups back together, many others in the room shared a similar sentiment around $5 being diminutive, though not as harshly stated. To everyone in the room, including myself, $5 was a trivial amount of money and would become even more trivial once an advanced degree from the University of Michigan and a job were secured. Medicaid recipients were quickly reduced to a group leeching off of the government whose behaviors needed to be controlled by an increased financial burden. The fact that they were human beings in need of assistance, many of whom we had just learned are children, was moot.
This disdainful expression of thought geared toward indigent and minority groups was common during our class discussions. I remember us covering the lack of diversity at medical schools, and thus physicians, and another white male being concerned that if we allowed more minorities into top medical programs, it may result in diminished quality, not considering that the strongest predictor of one’s educational success is family income and not ability or meritocracy, and that there are disparities in family income and wealth for minority groups compared to white Americans. On another occasion, an alum of the program and another white male, had come back to talk about his professional journey when he made the comment that a minority had gotten a job over him simply because he was a minority with no regard for the fact that the other person was likely (definitely) more qualified.
Conversation
It is not at all shocking that those who live in different realities misunderstand each other. I’m certain that someone from my childhood neighborhood would find it ridiculous to spend $5 on a side of avocado just as many of my classmates found $5 to be a trivial amount for a co-payment. The grim reality is that one group has power and the other group does not. From local all the way up to federal government, to the hospital administrators like many of my former classmates, to those at the head of large insurance companies administering state Medicaid programs, those making decisions about Medicaid and it beneficiaries are not, and have likely never been, Medicaid beneficiaries, nor do they interact with them on a regular basis. To qualify for Medicaid, your annual income must be 138% of the federal poverty level, meaning $12,060 for an individual or $24,600 for a family of four. The median household income in this country was less than $60,000 in 2016 and the average income for the heads of America’s top healthcare companies was roughly $20 million.
Social and financial capital are compounding. First there is the education gap, which we’d like to believe starts after high school when people are designated as adults and can make decisions for themselves to advance their life. However, education gaps can be seen as early as infancy and certainly in k-12. Individual discrimination in school aside, such as the tendency to punish Black students more harshly than white students for the same behavior or the diminished likelihood of Black students being placed in gifted programs even with the same academic performance as white students in such programs, public education is funded through property taxes which is determined by property values. With centuries of housing discrimination, there are disparities in property values and home ownership among Black Americans which results in disparities in quality of public education for Black students.
With education gaps come job and income gaps. Not only are those with an education likely to have better and higher paying jobs, they have more resources to understand basic money management, investment, and financial planning. Discrimination in hiring compounds the job and income issue. A researcher from Notre Dame found that US companies assumed Black people were less likely to have the necessary skills for jobs, would be unable to pass the necessary drug tests, and didn't consider them for positions based on that perception. In a study that has been repeated with similar results, researchers sent out resumes with “white sounding names” and “African American names” with comparable qualifications. The resumes with white names received 50% more calls for interviews. This disparity persists even at the most selective of positions where qualified applicants may be limited. A study found that Black graduates from Ivy league institutions, on average, are offered far less pay for comparable jobs and are less likely to be considered for positions than white applicants from less prestigious colleges.
This does not include the gaps in historical wealth accumulation, which for average Americans, is obtained primarily through housing and land, both areas that have been legally withheld from generations of Black Americans. First there was more than two centuries of enslavement and the theft of labor. Then there were Black codes during and after slavery that barred the ownership of land and businesses for freed Black people. Then there was the reneging by Abraham Lincoln’s successor Andrew Johnson on military special Field Order 15 which promised 400,000 acres of land to freed slaves in South Carolina, Georgia, and Florida (40 acres and a mule) and other programs like it after emancipation which sought to atone for the years of forced free labor and provide opportunity to America’s new citizenry. This land was returned to previous Confederate owners soon after the war. Then there was the stealing, both legally and by threat of violence, of the 15 million acres of land Black farmers were able to obtain across the south during Jim Crow. Then there were decades of discriminatory housing practices that barred African Americans from obtaining the federally backed mortgages that whites were granted through the Federal Housing Act across the country creating suburban America. In short, the Black community has been economically plundered in every fathomable way, leaving many African Americans concentrated together in deprived urban areas with 6 cents on the dollar in wealth compared to white families.
Not only does the amount of capital separate people, our biases work to separate groups as well, creating a pernicious cycle of prejudice. White Americans have a “tipping point” when it comes to the minority share of people in a neighborhood. Researchers found that general tipping points slowly increased between 1970 and 2000 topping out at around 15%, meaning at most, certain whites would tolerate a neighborhood with 15% minority people. Individual preferences to have alike neighbors balloons into complete segregation on the macro level. Whites who tolerate only 5% minority neighbors will move out and if/when only Black people replace them, then white people who will tolerate 10% move out, so on and so forth.
As social and financial capital gaps widen, in combination with societal biases, so too does our proximity to those with different amounts of it. This makes it difficult to not only understand the plight of those with different amounts of capital, but also to anticipate the challenges they face regularly. With educational attainment and financial stability comes improved health and general quality of life. Not only do you have access to better food and exercise environments and equipment, but you have at least basic dietary knowledge, and if you don’t, you have the resources to attain it. You have a peace of mind that a car malfunction or health issue won’t send you into financial devastation. When certain barriers are not part of your life, you do not appreciate their hindrance on the lives of others, and your ability to be thoroughly and genuinely empathetic is diminished.
There is Hope
Negative biases about indigent and minority populations are never refuted when we seldom encounter those people. Social proximity in culmination with bias, results in a society where we are insensitive in our thoughts and beliefs about groups of people and explain societal disparities away with the biases we are taught to have. However, just as these biases were developed they can be dismantled. Once the basis for our rationale behind human suffering is broken, namely our biases, we can begin to become more empathetic to the basic needs of others. We must be deliberate in our efforts to understand other groups of people. One of America’s greatest strengths is its diversity. However, it will be an Achilles heel if certain groups are ignored and stigmatized. The very presence of people that are disenfranchised by the powers at be are a contradiction to American principles and a threat to the stability of American democracy not just politically, but also culturally. As the late James Baldwin said, "Ignorance, allied with power, is the most ferocious enemy justice can have."