As the Senate works on its tax bill, it seems like a good time to discuss connections that may not be obvious between this bill and the inequality, injustice, and attitudes about race that are major barriers to better health in America. I have long hidden the fact that issues of race still confuse me. Compared to other white Southern families in the Jim Crow South of the forties and fifties, my family had a progressive attitude about race; yet, like many white Southern families, we rarely talked about race. We lived in such an effectively divided community that it was rare to encounter uncomfortable interactions.

Don Berwick taught us that medical errors and poor quality were usually not individual failings, but systems issues. I reasoned that race and poverty were both systems issues to be decided by someone wiser than me. Patty Gabow’s analysis shows that health is a systems issue with prominent social components of race and poverty.

I was reminded of the inequality that exists in healthcare and health when my 97 year old father was hospitalized recently where he lives in North Carolina. He was the beneficiary of fabulous care and is now much better. Not every person in North Carolina has access to the kind of care my Dad is enjoying.

My father was born into a poor family in a mill community in South Carolina in 1920. Everyone there suffered during the Depression. As the economy gradually improved, he was able to be the first person in his family to go to college. In the growing prosperity that followed World War II, our family reaped benefits that we would not have enjoyed if we had been a black family anywhere in America.

The benefits that my family has enjoyed have been multigenerational. I attended racially segregated public schools that were much better than the schools available to the poorer African American students in my community. I was well positioned to qualify for federal funds that made my medical education virtually free. It is easy to feel like “we earned” the benefits we enjoy, and neglect the fact there are others who probably worked just as hard and have benefited less because they are black.

In 2013 there were 1.5 million (16%) North Carolinians without access to healthcare. North Carolina is one of the 18 states that has not accepted the Medicaid expansion and some of its congressional representatives, like Congressman Mark Meadows, are some of the most anti-ACA members of Congress. Nevertheless, because of the ACA, there are now only a little over a million (about 10%) North Carolinians who lack coverage. It is estimated that as many as a million North Carolinians will lose their care if Congressman Meadows eventually gets his way.

What the disgraced former senator from North Carolina, John Edwards, said when he ran for president remains true. There are “two Americas.” When it comes to health and race there are two North Carolinas, just like there are two New Yorks, two Californias, and two Alabamas. Each state has some unique social problems, but the states of the old South are especially challenged by remnants of the Jim Crow infrastructure that persisted for a hundred years after the failure of Reconstruction.

Those laws and the customs and culture they perpetuated were built on lies of racial superiority and the twisted concept that natural and divine forces supported the wisdom of the races living in parallel communities with little intersection. Those of us who were not the target of those discriminatory laws were, and still are, hugely advantaged. The laws are gone, but the legacy of Jim Crow lives on in ways that are easy to discern if you allow yourself to look. You can smell the lingering odor of Jim Crow under the covers of healthcare, education, employment opportunity, housing policy, and in the criminal justice system. What discourages so many is the fact that it lives on despite marginal improvements that make us want to assert that it is dead. 

The Confederate monuments and artifacts that are so ubiquitous across the South are symbols that supported and perpetuated the divide that I can still see today more than 50 years after Martin Luther King, Jr. gave his “I Have a Dream” speech. Before you tell me that things have changed tremendously since the mid sixties, let’s look at Dr. King’s description of a post racial world:

I have a dream that one day this nation will rise up and live out the true meaning of its creed: “We hold these truths to be self-evident: that all men are created equal.”…I have a dream that my four little children will one day live in a nation where they will not be judged by the color of their skin but by the content of their character.

His words remind us that slavery may be over, but we are still far from “the dream.” The color of a person’s skin still determines many opportunities, and trumps the assessment of the character of most black Americans by white Americans. Jim Crow’s ghost still haunts us, and there is no better place to sense that ghost than when we look at the metrics of healthcare and health, and sort the results by race. Many Americans, white and black, North and South are still denied access to good health and economic opportunity.  But, I am biased that the sum of all the history and circumstances that create inequality in this country has had its greatest and most prolonged impact on black Americans.

Everyone’s lot is better than it was 65 years ago when I first began to recognize that race was a powerful reality in my world. Nevertheless inequities persist, and it feels like the gap is wider between poor black Americans and everyone else. The gap is indefensible. We rarely ask why it exists or why progress toward equity has been so slow.  Is it because we follow leaders who have different concerns and don’t see improving the plight of the poor of all races as a priority? Perhaps we are so far from the dream because we have not treated issues of economic and racial injustice as a disease that harms us all. Whatever the cause, the plight of the poor, and especially the black poor, is always explainable in terms of their personal defects rather than as a function of their systematic exclusion from real opportunities.   

In Just Mercy: A Story of Justice and Redemption. Bryon Stevenson, one of the  founders of the Equal Justice Initiative, summarizes what his life work has taught him.

My work with the poor and incarcerated has persuaded me that the opposite of poverty is not wealth; the opposite of poverty is justice. Finally, I’ve come to believe that the true measure of our commitment to justice, the character of our society, our commitment to the rule of law, fairness, and equality cannot be measured by how we treat the rich, powerful, the privileged, and respected among us. The true measure of our character is how we treat the poor, the disfavored, the accused, incarcerated, and condemned….An absence of compassion can corrupt the decency of a community, a state, a nation. Fear and anger can make us vindictive and abusive, unjust and unfair, until we all suffer from the absence of mercy and we condemn ourselves as much as we victimize others.

His words reminded me of Hubert Humphrey’s quote carved into the walls of the Health and Human Services building in Washington:

The moral test of government is how it treats those who are in the dawn of life, the children; those who are in the twilight of life, the aged; and those in the shadows of life, the sick, the needy and the handicapped.

The similarity between Humphrey’s quote and Stevenson’s insight is even more obvious if you include “health” with “justice” in the quote I have lifted from Just Mercy. Don’t forget that according to Dr. King: Of all the forms of inequality, injustice in health care is the most shocking and inhumane. Both quotes promote the idea that we are all diminished by the difficult experiences that befall any of us.

The reality that we all are diminished when anyone is treated unfairly brings me to the current tax reform attempts. Paul Krugman shares my concern that it is the poor and underserved who will suffer the most if the Republicans are able to pass a bill anything like the one the House has approved and that the Senate is considering.

..Meanwhile, funding for the Children’s Health Insurance Program, which covers more than eight million children, expired a month and a half ago — and so far, Republicans have made no serious effort to restore it. This is surely the shape of things to come: If tax cuts pass, and the deficit explodes, the G.O.P. will suddenly decide that deficits matter again and will demand cuts in social programs…

Everyone has been talking about how the Republican tax proposals advantage corporations and the rich disproportionately to the middle class. The real issue that has moral impact has been ignored. Until recently little has been said about how the tax bills would undermine programmatic efforts to address the causes of poverty and the social determinants of health.

As the Republicans struggle with the “math” of the reconciliation process they are discovering that to fund their tax plans they need to ramp up their war on “entitlements” and benefits to the underserved and disadvantaged. As Senate Republicans try to fit the square peg of their tax gift to the wealthy into the round hole of the “reconciliation process,” they have realized that by eliminating the hated “mandate” in the tax reform bill they kill several birds with one stone. Saving $300 million going to 13 million people who lose their care will reduce the federal deficit toward numbers that allow passage of the bill with the votes of just 50 Republican senators.

Eliminating the mandate will not be the end of things. Republicans seem to be turning the mission of tax reform into an attack on entitlements. Could it be true that tax reform is not a strategy to improve the economy, but is really just a tactic in the more important Republican strategy of gutting entitlements? For years I have heard rants about women who are “welfare queens” and men who abandon their responsibilities and are lazy drug using welfare recipients. If some form of the current tax bill is passed, inequality will be enhanced, and we will all be disadvantaged.

I worry that “Make America Great Again” is a dog whistle call for reinforcing white privilege. I believe that a Great America wants to make real progress toward improving health for all Americans. To do so we must embrace the reality that we have allowed inequality to exist along lines defined predominantly by race. Our concern should be to embrace equality for all Americans of all races and apply a justice that effectively addresses the issues of inequality and race that perpetuate poverty. We must accept that race and poverty are very connected issues that endanger the future of us all.

The “gated community” is the symbol for me of the ultimate destination of the road we seem to be on. Having “more” does not diminish fear or offer much protection from our fears that we fantasize can be eliminated by better walls, guns, and self serving legislation. Stevenson nailed it when he said:

We are all implicated when we allow other people to be mistreated. An absence of compassion can corrupt the decency of a community, a state, a nation. Fear and anger can make us vindictive and abusive, unjust and unfair, until we all suffer from the absence of mercy and we condemn ourselves as much as we victimize others.