When Medicaid was established in 1965, it was instrumental in providing healthcare to America’s least privileged populations. It allowed impoverished Black Americans (who were and still are disproportionately affected by poverty) the opportunity to seek medical attention without financial burden, as well as gave way to racial integration of hospitals. Medicaid expansion efforts since the 2010s have been shown to reduce instances of poverty, meaning Medicaid goes beyond healthcare and actually improves the overall lives of those who use it. But even with it’s stunning benefits, it’s no surprise that Medicaid hasn’t magically fixed everything. Countless examples and personal testimonials from people we know tell us that the American healthcare system is full of flaws – people die because they can’t afford to buy insulin. Especially for Black Americans, Medicaid can only do so much – it can provide some assistance for some people, but it can’t control doctors.

Let’s start with Opioids. For the Black community, the opioids highlight a variety of problems. Firstly, the way we talk about opioid addiction and death is often framed around compassion. There are exceptions – I have personal experience with people who see those struggling with addiction as careless, bad people. Politicians, news anchors, and our random neighbors down the street have posited we shouldn’t give away narcan for free or fund safe injection sites because it’s “enabling”. But aside from these crass opinions, the national perspective is that people addicted to opioids need help. We realize the overwhelming culpability of opioid manufacturers and pharmaceutical distributors in this crisis. We don’t want to see users go to jail for having a disease.

This perspective is quite different than the one we held a few decades ago with crack cocaine. It’s a well known fact that Black people were specifically targeted for cocaine use in the form of crack, and instead of treating their addictions as terrible diseases, we put them in jail. We didn’t stop to wonder what traumas (or even simple naive mistakes) could lead a person to use drugs, we never considered what economic hardships would lead a person to sell them. Black people were arrested by the thousands, and decades later, many are still incarcerated (to learn more about this, I would highly recommend you watch the Ava DuVernay documentary 13th, or give this report by The Sentencing Project, or this article by the ACLU a read).

Crack was something low income people had more access to from the 1970s to 90s. Cocaine was big among movie stars and the white elite, while crack was running through less wealthy American communities. There’s no difference between the two drugs besides who used them – but guess which drug put people in jail. I think the main difference between crack addiction and opioid addiction is that different types of opioids are used more interchangeably among demographics.

Opioids like fentanyl or heroin are used by the elite, the poor, and the average middle-class worker. Lil Peep and Mac Miller, young, beloved, and successful musicians both used fentanyl, Academy Award winning actor Phillip Seymour Hoffman died from heroin and cocaine use, Michael Baze, a horse jockey, died from oxycodone. Those are the same drugs that kill poor people. I don’t want to take away from the tragedy and scale of opioid use and death, but it’s important to understand that this epidemic is being treated differently than that of crack and cocaine in the past, and it’s probably because white, wealthy people are using the exact same drugs as poor, Black people.

Another lens to look through with opioids is prescriptions. The percentage of the Black population that suffers from opioid addiction is around 4%. This is in line with the national percentage and the percentage of white people who use opioids (CITE). But interestingly, white people are more likely to have developed their addiction from a prescription. According to a study published in the Cureus Journal of Medical Science, those who received opiates from an emergency room visit were more likely to be white, young, female, and have private insurance (as a horrific side note, between 2011 and 2016, one third of all emergency room visits ended with an opioid prescription, turning a person’s emergency pain into a life threatening addiction).

Obviously, in hindsight, we can see that not being prescribed opioids may have been a good thing. For once, being Black in America actually may have benefited some people. But there are nuanced reasons why white people are more likely to leave the ER with opioids. For one, they are more likely to have insurance. 58% of Americans are covered by insurance provided by their job – 66% of those people are white, while only 47% are Black (even lower percentages of Latino and Indigenous people are covered).

Black Americans are more likely to work at jobs that do not provide adequate insurance or any insurance at all, meaning they often have to pay out of pocket when seeking medical assistance. People who don’t receive insurance from their employers are more likely to be uninsured – Black people are 1.5% more likely to be uninsured than their white counterparts.

Another reason why opiate prescriptions for Black people were lower is because of centuries’ old myths. Doctors and laypeople alike all sort of believe Black people and white people are biologically different. In a well cited 2016 survey, 25% of medical residents said they believed Black people had thicker skin than whites. In the early days of COVID-19, when Black people were becoming infected with the virus at higher rates than other groups, it was suggested that Black people were genetically predisposed to Covid. The truth was that Black people were more likely to be essential workers and had jobs that didn’t allow them to work at home.

These myths and many others go back to American Slavery. With the dawn of medical exploration coinciding with slavery, doctors at the time used enslaved people to experiment on. The enslaved were property – unable to consent and easy to own. They were chosen for experiments because nobody thought twice about treating them inhumanely and expected constant “willingness” and “cooperation”. Along the way, doctors (somehow forgetting they were practicing on people unable to object) formed the belief that their Black patients experienced less pain than whites. The now infamous Dr. James Sims was, until recently, called the “father on modern gynecology”. He perfected a technique to repair rare vaginal fistulas, a technique still used today, but he did so by repeatedly conducting his experiments on unanesthetized enslaved women. He didn’t believe these women, or any woman, should feel pain during his procedures – this is in spite of his own writings which detail how his enslaved patients would cry in pain. In a 1950 biography of Sims, his beliefs were still being reinforced – the book read that his patients were able to bear his experiments because of “their racial endowment”.

Sims and most other doctors at the time believed Black people had thicker skulls and skin, and less sensitive nerve endings. Because these doctors wrote about their medical findings, some of which were actually legitimate, their skewed beliefs about Black pain tolerance were passed down through several generations of doctors and healthcare providers. Nobody second guessed it. If Sims was right about fistulas, and if all the doctors at the time were saying the same thing, why would the “pain tolerance thing” be wrong? Today, we can still see these beliefs at work. For example, according to a JAMA Pediatrics study, Black children are less likely to receive the same amount of pain medication as white children for appendicitis.

As noted in previous articles, Black women are a lot more likely to die from childbirth than white women. Similarly, Black patients are often subject to implicit bias when they talk about pain to their doctor or nurse. Some may think they are exaggerating about their pain and don’t take it seriously, others are suspicious that Black patients are seeking pain killers to misuse (check out this article by the Association of American Medical Colleagues, or this article by healthline for more information).

Medical student Malone Mukwende created the book Mind the Gap to show other students and doctors how certain health conditions look on different skin tones. His book is one of the first and only examples of racially equitable health education. As you can find in researching, most doctors do not learn their practice with non-white patients, cadavers, or medical drawings. Curriculum that addresses physical symptoms on different skin tones is not a requirement at most medical institutions. As experts will tell you, this lack of education leads medical students and doctors to believe there are biological differences that cause Black people to have certain health conditions, rather than social conditions that lead to poor health. They don’t get the chance to learn otherwise, and are stuck learning facts passed down from slave doctors. They are never given bias training to unlearn dangerous prejudices, leaving them to misdiagnose or undertreat their Black patients on the road ahead.

All of this information – opiates, the war on drugs, experiments on enslaved people, implicit biases – they all lead to institutional racism. I hope you research this topic further, starting with this Health Affairs article, but the main thing to take away is that Black Americans have never been afforded the same healthcare experiences as white Americans. The U.S. finds new ways to sidestep advancements and disenfranchise low income people, most of whom are Black. The doctors who fail to adequately treat their Black patients are a symptom of a country that can’t shake its racism. Change starts at the top – it’s up to us to be informed and demand action.