Segregation is baked into the way people and institutions discuss health care at its most basic levels. Racial differences in almost every health outcome—from infant mortality to life expectancy––are obvious and pronounced, especially between white people and black people. Perhaps because of the sheer size of the evidence of health disparities, all sides of health-policy debates acknowledge their existence, a consensus that has yet to be achieved in debates about education or criminal justice. Yet segregation in health care is rarely discussed in those terms, and its importance in shaping the larger narrative of race in America is often ignored.

Like other forms of segregation, health-care segregation was originally a function of explicitly racist black codes and Jim Crow laws. Many hospitals, clinics, and doctor’s offices were totally segregated by race, and many more maintained separate wings or staff that could never intermingle under threat of law. The deficit of trained black medical professionals (itself caused by a number of factors including education segregation) meant that no matter where black people received health-care services, they would find their care to be subpar compared to that of whites. While there were some deaths that were directly attributable to being denied emergency service, most of the damage was done in establishing the same cumulative health disparities that plague black people today as a societal fate. The descendants of enslaved people lived much more dangerous and unhealthy lives than white counterparts, on disease-ridden and degraded environments. Within the confines of a segregated health-care system, these factors became poor health outcomes that shaped black America as if they were its genetic material.

The sweeping tide of Civil Rights papered over the fissures that were built into Jim Crow-era health-care, but progress was slow and proved much more difficult to assess than progress in education or housing. Generations of strict geographical segregation left hospitals that served black people deeply segregated, understaffed, and under-resourced. The number of black physicians has never come close to matching their demographic share of the total population. Unlike the temporary integration gains in education, there is no real high-water mark for the state of health-care integration.

The 2010 passage of the Affordable Care Act aimed to set that mark. The ACA functioned as a stealthy civil-rights achievement of the Obama presidency, promising to make health care less of a financial burden, end disparities in health-care coverage, ease barriers to access for people of color, and subsidize preventative health-care services that proved especially lacking in black neighborhoods.

Although the ACA has undoubtedly succeeded at some of those metrics and is still being evaluated for some others, the Supreme Court’s 2012 decision in NFIB v. Sebelius seriously weakened its most key provision. The broad Medicaid expansion to poor people was effectively turned into a state opt-in, and state decisions to expand Medicaid have so far been largely based on ideological grounds. Southern conservative governors and legislatures opposing the ACA on party lines or concerns about expanded federal authority and the costs of the program have formed most of the resistance to the ACA. And many of their states have large black populations. Seven of the ten states with the highest black populations chose not to expand Medicaid. Overall, more than half of the people who are now categorically unable to access any affordable health coverage are people of color. Thirty percent of people without affordable coverage options are black.