The contemporary debate over healthcare in the United States revolves around an unstated but somewhat widely understood notion of what people deserve. The question of “deservingness” is particularly important when we hone in on the demographics of the American populace and think critically about who is currently underserved by the current medical system in the U.S., and who stands to benefit from an improved and more accessible system. As the politics around healthcare become increasingly imbued with the ambitions and desires people hope to realize in other aspects of daily life, the healthcare debate has come to resemble a proxy war of sorts, pitting social welfare proponents against capitalist hawks who believe in little government and every man for himself.

In effect, the U.S. healthcare debate is hardly just about health. Healthcare, representing a politics by other means, helps determine the socio-political and economic futures of women, Black people, and Black women, beyond the intrinsic health outcomes it directly produces. Therefore, a single-payer approach to healthcare has far-reaching potential beyond simply paying for care; it could be a lynchpin in reducing abortion-related morality for all women, reducing Black maternal mortality, and improving health outcomes for Black people more generally, via increased healthcare usage rates. Under such considerations, the moral underpinnings of a Medicare For All approach or an insurance-based healthcare payment scheme are all the more apparent. Proponents of the former system argue for the health-related and social benefits a universal healthcare scheme would produce. However, a Medicare For All program may prompt us to examine notions of merit and deservingness that have up to now, been deployed to entrench racial inequality within existing American social structures.

Health and Politics of Deservingness

As a capitalist nation that is increasingly siphoning off governmental and social projects to the avarice of private corporations and the “free market,” the U.S. has for centuries taken the stance that communal/social projects are antithetical to an American ethic of benevolence.  It is this long-taught ethic, this conceptual branding, that envisions America as a land in which “nothing is given, everything is earned.” However, leaving aside explanations about American conservatives’ and liberals’ misunderstandings of socialism and the enduring history of socialist projects and traditions within America, the fight against Medicare For All or single payer hinges on the question, “do people deserve free healthcare?” In a country where the idea of having the government provide fundamental provisions like healthcare is devalued,  the question of people’s deservingness emerges at every turn. Amid these debates, a further question emerges: “which people deserve free healthcare?”

Throughout history, white people, the U.S. government and those committed to upholding a paternalistic and anti-Black socio-political regime in America have denied that Black peoples and other people of color deserve the benefits of citizenship. Unfortunately, Black peoples’ abilities to participate in American society is often problematically reduced to tropes of government handouts and welfare, violence, drug use and most recently, “un-American” and “ungrateful” protests against police brutality. For example, when Black Americans’ exercise the right to free expression to claim sociopolitical dissatisfaction, their sentiments are often framed as anti-American disrespect. Again, the subtext reads that “Black people don’t respect how well they have it, they had a Black president and they’re living better than people elsewhere.” The nationalist response to the protest of police brutality and racism has repeatedly involved telling protesters to shut up and if they don’t like it, “go back to Africa”.

White Americans have demonstrated through words and actions that they think Black folks do not deserve the benefits of American citizenship. A 2016 HuffPost/YouGov poll asked half of its participants to respond to the statement, “Over the past few years, blacks have gotten less than they deserve,” whereas the other half of the sample were asked to respond to the same statement where the word “blacks” was replaced with “average Americans,” a group that research has shown to be implicitly synonymous with whiteness or white identity. Of the full sample, 57 percent of respondents said that “average Americans” are not receiving what they deserve in society; however only 32 percent of respondents said they felt that Black people were getting short shrift in America. A majority of respondents who identified as white (58 percent) agreed that they are failing to get what they deserve in America, whereas only 28 percent of them felt that Black people have received less than they deserve. Put simply, in the eyes of white Americans, Black people are getting at least what (white Americans think) they deserve, and some think that Black people are getting more than whites. In a 2017 Pew research poll, respondents were asked if racial discrimination, as opposed to personal actions, is holding back African-Americans who can’t get ahead, and only 41 percent of Americans agreed with this view, with 49 percent stating that Black people who fail to succeed in this country are mostly responsible for their own circumstances, with 54 percent of whites stating that Black Americans themselves, not the effects of systemic racial discrimination, are responsible for their inability to get ahead in this country. These two separate questions and related findings illuminate different sides of this Black deservingness issue in the US:

1. White people feel that Black people are getting too much, seemingly at the expense of White people (who probably feel they deserve more than Black people).
2. White people feel that Black people, not systemic inequalities and injustices, are solely responsible for their own circumstances.

According to the above logic, White people would be responsible for their own inability to “get what they deserve” from America, and thus, are actually getting what they deserve. However, while these two ostensibly related trains of thought emerge from the same position of whiteness and white priorities being central to the body politic, they never seem to intersect in the minds of folks debating deservingness with regard to healthcare. Given this lacuna in the above logic as it relates to the question of Black deservingness, specifically, Medicare For All – which systematically includes all Americans in the provision of healthcare — could serve as the first crack in the wall that is this powerful discourse on what Black people deserve.

Establishing a floor for inclusivity by providing healthcare for everyone and in effect, nullifying any question of deservingness criteria, could soon prompt Americans to reevaluate their ideas on deservingness and merit as well. If Black people and White people were included in a system of government-sponsored healthcare, would not White people begin to or be persuaded to consider themselves in the same social-health predicament as Black people? In other words, Medicare For All could provide a mitigation of some health inequalities that Black people experience and that White people simultaneously perceive as non-existent. Putting everyone in the same lot forces the dominant group to reconcile how it has and continues to perceive the existential and material conditions that Blacks experience and endure in America, in terms of healthcare and otherwise. Through a universal healthcare approach, White people may come to see themselves, or at least see projections of their experiences dealing with health and healthcare issues, in relation to the experiences of Black people. Medicare For All could both radically shift the way people think about what other people deserve, and cause people to reevaluate or critically reexamine the criteria by which they measure their own deservingness of healthcare and other social benefits afforded by the state. Even if Black people achieve health gains across-the-board in an equitable health-providing system, that alone will not sway people to change they way they perceive or understand fairness or deservingness of American benefits. Yet, following the aforementioned logical trap into which many White Americans fall when criticizing Black Americans as being solely responsible for the negative health conditions and experiences they suffer, White Americans would have to face the possibility that they would have the same, if not worse health outcomes as Black Americans. How would people reconcile noticeable jumps in quality of healthcare experiences and positive healthcare outcomes among Black Americans? And if Black Americans end up achieving care that mirrors that of White Americans, or even surpasses it, would that be reflected in criteria that measure deservingness? In other words, if Black Americans sustain better health outcomes, is it because they are responsible for them? In turn, if White Americans find themselves experiencing parity of healthcare outcomes with Black Americans vis-à-vis universal healthcare or even demonstrating worse measures of health compared to Black Americans, will they see their inability to maintain better health relative to Black Americans as their fault?

No one would say that Black Americans are getting “too much” since, in terms of healthcare, they would ostensibly receive the same access as everyone else. However, they would also not be receiving benefits at the expense of White Americans, invalidating the complaint many White Americans have lodged, which is that whatever Black people receive or earn comes at the expense of White people and others. Through Black health gains via universal healthcare, only the (often unstated) myth that White people “earn” their high rates of positive health status and outcomes relative to Black people, by virtue of some attention to care to their bodies and minds that other groups, including Black people, do not employ, would fall. There is nothing intrinsic to Whiteness that renders people more healthy or deserving of health than others; however it is institutionalized and systemic racial inequalities—including access to quality care—that has proven critical in explaining the huge persistent gaps in healthcare outcomes between Whites and Blacks. A universal healthcare system and attendant health gains among Black people would demonstrate the cruel fictions of the myth that Blacks don’t deserve healthcare because what they get (poor health and poor health outcomes) is what they deserve.

Establishing social systems that ensure inclusion, equal access and equitable participation could foster more enduring legacies of Black presence and engagement in systems that were previously built on racial segregation and exclusion. Put another way, the social fact of Black people having access to care in the same ways as Whites may become normalized, and more commonplace, thus obviating the use of deservingness criteria that have served as anti-Black gatekeepers of the benefits of American socialized care for generations. With recent polls showing shifting perceptions of Americans, in which increasing percentages of people express the belief that the government doesn’t spend enough on improving the conditions of Blacks, a Medicare For All system could further shape Americans’ perspectives on racial inequality within the country. People are already reevaluating their feelings on the government’s efforts to provide for Black people in the U.S.

Gender and Healthcare in the U.S.

In addition to the potential of Medicare For All to shift culturally-held notions of deservingness more broadly, a single-payer system could provide a safeguard for the rights of women, and especially Black women, to exercise control over their own bodies. Healthcare provision in the U.S. is both gendered and racialized, and Black women uniquely suffer from high health insurance costs, laws against abortion, including the many policies and amendments that make abortion difficult to receive, and low access to maternal healthcare, resulting in high maternal mortality rates among black women.

The Hyde Amendment, a 1976 congressional appropriations rider that was passed in response to the 1973 Roe v Wade case that legalized abortion, prohibits the use of federal dollars to pay for abortions except in the case of rape, incest, or life endangerment. Women seeking to undergo an abortion procedure would have to otherwise fork over $500 and often much more if the pregnancy progresses into the second trimester. The Hyde Amendment has made receiving abortions covered by Medicaid nearly impossible for most women, especially low-income women and women of color, forcing the already economically disadvantaged to pay exorbitant amounts of money for either licit abortions in U.S. clinics or over-the-counter pills acquired in the U.S. or Mexico. Universal healthcare would essentially extend abortion coverage to everyone, annulling the Hyde Amendment.

Further, guaranteeing health insurance for everyone would effectively nullify some of the effects of job and wage discrimination that tether women’s healthcare coverage to a (typically male) spouse. Universal coverage would enhance and ensure women’s economic and social independence because healthcare would no longer be contingent upon employment or marital status. Black women, who make less than $0.70 of every dollar white men make, experience both sex and racial discrimination in terms of hiring, pay, and promotion in the workplace, hampering their abilities to care for themselves and perform the unpaid labor of caring for their families, often at the expense of their own health.

Black Women and Improved Access to Care

According to the CDC, Black women in America are 243 times more likely to die from pregnancy-related causes. With racism, not race, being the problem Black women face, social inequalities such as differential access to quality food, safe neighborhoods, good schools, adequate jobs, and reliable transportation contribute to the increased Black maternal mortality rate. Additionally, Black women are more likely than other demographics to be uninsured outside of pregnancy (which is when Medicaid is activated, meaning non-pregnant Black women are more likely to be uninsured compared to other women), and thus, are more likely to begin prenatal care later and to lose coverage in the postpartum period. Studies have shown that Black women’s poor access to care, especially reproductive care, has contributed to Black maternal health disparities within the U.S. Black women are also more likely to suffer chronic conditions such as obesity, diabetes, and hypertension, which pregnancy more dangerous for both mother and child. Uterine fibroids – non-malignant tumors – affect upwards of 80 percent of Black women, leading to heavy menstrual bleeding, anemia, pelvic pain, and fertility issues, of which Black women are almost two times as likely to experience than White women. Some of these issues that have continued to doggedly harm Black women for generations can be directly addressed by expanding access to healthcare via universal coverage.

In April 2018, The National Partnership for Women and Families outlined a multifaceted approach to addressing enduring and pernicious health disparities that affect Black women, which includes:

• Provide patient-centered care that is responsive to the needs of Black women.
• Address the social determinants of health.
• Expand paid family and medical leave.
• Expand access to quality, patient-centered and comprehensive reproductive health care.
• Expand protections for pregnant workers.

Black people and especially Black women would experience more positive health outcomes due to increased access to healthcare via a universal healthcare program. However, such improvements in health for Black people could only be realized if they are met with a substantive commitment to addressing other disparities within the context of social inequalities that have an outsized affect on Black Americans, such as food deserts, environmental racism, and school segregation. Finally, by mitigating racial disparities within healthcare, a universal provision system could reasonably facilitate better socio-economic positioning with respect to other social issues that are affected by health. For example, with universal healthcare, families would presumably have much lower medical expenditures and would spend less time away from work due to sickness, mitigating wage loss from poor health. More money that families can spend via health savings can enable them to invest in other aspects of their lives, including personal or child enrichment activities (such as vacation or sending a child to summer camp) or be used to cover incidentals and emergencies that often exact huge financial tolls on middle class and low-income families of color). Again, universal healthcare will not alleviate all social or even health disparities that Black people and Black women, specifically, experience; however Blacks stand to gain the most from a more economically equitable healthcare system.

Currently, Medicaid is under attack by social and political conservatives who think the program is mainly used by freeloaders who would rather be on Medicaid than work. Such attacks reveal the capitalistic mindset of many conservative Americans, evident in efforts to revise the eligibility criteria of the program due to more people on Medicaid without children — people who conservatives think should be working. Recently, a federal judge blocked new Medicaid work requirements in Kentucky and Arkansas — draconian measures by the Trump administration to further tie healthcare benefits to wage labor and economic (surplus) value. The prospect of universal healthcare runs along major political and moral fault lines of this country, namely culturally-held notions of deservingness, and personal responsibility.

Indeed, many Americans, liberal and conservative, hold those sentiments of personal responsibility — that everyone should “get their fair share” — and extol the virtues of the free market over the immorality of socialized benefits. In contrast, universal healthcare directly undermines conservative arguments that people deserve whatever they get within the free market, and that the government should not provide for healthcare because it is the personal responsibility of the citizen. Yet, when we think about health care, what are we really talking about? Are we just talking about people’s health, or are we talking about something else, something more? Namely, “who deserves health and in what form?” and “who should get healthcare and at what cost?” These questions of deservingness, access, and (in)equality continue to anchor debates about healthcare in the U.S. By providing health care for all, a single-payer system would fundamentally threaten these practices of exclusion and reshape the ideas of deservingness that underpin them.

As a part of the contemporary cultural zeitgeist in the U.S., Medicare For All is forcing Democrats and progressives to determine their stances on the debate before the upcoming 2020 presidential elections. The possibility of single-payer healthcare is an especially important issue for voters, since universal coverage could dramatically alter the way Americans experience and engage with the healthcare system in this country. Many of us, myself included, have had to spend hours on the phone haranguing insurance companies for … literally anything resembling an explanation of some dubious letter we received in the mail, telling us we owe… how much?! We get it, our current system is broken, or at least, it never worked for us anyway, and we want—we need—something better.

What would a healthcare system that provides all manner of medical services and healthy living opportunities mean for Black Americans? The possibilities that would open up may be tremendous, and such a system, with all the research that supports the notion that alleviating health issues could benefit lower income and disadvantaged people of color, could drastically alter the health and even economic horizons for Black folks in America. Now, Medicare For All should not be mistaken for reparations or even a method of restorative justice for a people who have long languished in the crucible of anti-Black political, legal, and educational structures in this country, and who continue to suffer incredible injustices in service of protecting the “safety and ego of White Americans. What I am saying is that universal healthcare could provide what other laws and grand policy projects have failed to deliver: a way to ensure, in the writing of the law, a system that applies to all Americans and includes, in its original charter, a means to provide for the provision of health to Black people. Imagining a system that could actually provide a throughway for Black Americans to collectively overcome some of the issues that have been shown to disproportionately affect communities of color (heart disease leading to early death and lower life expectancy than white folks, diabetes, low mental health counseling use by black folks, especially black men, etc.) is not a mere thought experiment. Rather, such potential exists in the promise of Medicare For All.  Until now, no system that has bearing on much of our daily lives—not education, not the legal system, not the justice system—has ever been written with Black people as constitutive beings in the U.S.

Universal healthcare or single-payer healthcare will ostensibly address questions of healthcare access among Americans. Improved access alone cannot reverse all the other institutional issues in the medical system, such as the pervading myth of Blacks being able to endure higher rates of pain relative to whites, the racism that exists within medical school teaching and medical school minority student recruitment, or physicians’ racial bias that can lead to patient distrust of medical doctors and ultimately increased healthcare dissatisfaction among patients. Such a program could also render invisible some of these inequalities within healthcare, thus exacerbating many of the health disparities that universal healthcare access cannot address.

However, it is still important to wonder if such a system that transforms access extending it to everyone could lead to better health outcomes and translate those experiences to better life outcomes for Black people and other people of color in the U.S. Many of these issues, branded by social and political conservatives and even many well-to-do liberals as problems of poor decision-making and personal responsibility, could be addressed head on by a system that could approach a structural reckoning for how we collectively perceive and understand the broad rubric and phenomenon that is “health.” Put another way, a new approach that includes everyone under its auspices may force us to reconcile how and why we think about health as a commodity, something accorded to people on the basis of personal “choices,” and will compel us to reframe how we think about health outside of our current racial-capitalistic paradigm.

Many Black people across the country, especially Black women, as well as Black queer and trans women, are vigorously campaigning for Medicare For All or universal healthcare. They aren’t doing so because they want handouts; rather, they are demanding that a system that was never for them, or for anyone but the rich, be accountable to them and provide actual healthcare, not insurance premiums. They are advocating for a new way of caring in these wildly indifferent political times, and are also aware of what such a new health paradigm means: that we will have to renegotiate our relationship to health, healthcare and the politics of merit and deservingness that many of us, Black folks included, have ingrained in our moral and political constitutions.

---

Ampson Hagan is a PhD candidate in anthropology at the University of North Carolina and is currently living in Niger. Ampson studies how idioms and metaphors of health-related deservingness (who deserves care vs. who does not) affect migrants’ subjectivities and experiences of humanitarian care. Ampson spends his time in Niger talking to folks and remarking on all the ways people use deflective and subtle language, like idioms, metaphors, and euphemisms to determine value and merit with respect to social programs. Ampson also writes about race and health in the U.S.