As the Supreme Court Weighs Health Care, Black Women Stand to Lose the Most

Health care and various reproductive health rights are squarely within the U.S. Supreme Court’s crosshairs now that Amy Coney Barrett has taken her seat on the court. Next week, the justices will hear oral arguments in California v. Texas. Their ruling in this case will ultimately determine whether the Affordable Care Act’s individual mandate is a constitutional tax and, if not, whether the ACA can stand without the individual mandate. Justice Barrett appears poised to invalidate the ACA’s individual mandate, as she views this critical feature of the law as unconstitutional, and the court’s prior reasoning upholding the mandate as “illegitimate.” Meanwhile, 18 cases concerning abortion rights are pending in the federal appellate courts and are just one step away from the Supreme Court. On this issue, Judge Barrett has stated that she believes abortion can be limited through “how many restrictions could be put on clinics.”

The impact of an ultraconservative Supreme Court on Black women — who will undoubtedly bear the brunt of restrictions in access to health care services — cannot be ignored. Black women are disproportionately uninsured and susceptible to worse health and economic outcomes as a result. Without intentional counteraction at the local level, this Supreme Court could not only worsen but cement longstanding racial inequities for years (and likely generations) to come.

Several studies have shown the ACA’s success in improving health care rates for Black people and other people of color. Prior to enactment of the ACA, 27.1% and 43.5% of Black and Latino people were uninsured, respectively. After full implementation of the ACA in 2014, the number of uninsured Black and Latino people declined by 20% and 17%, respectively. In the year following full implementation of the ACA, 15 million Black people had already gained coverage for preventive services and screenings without cost sharing. The uninsured rate of Black people had dropped by over a third by 2016. And, according to the Center for American Progress, “there has been an increase in the share of black women with a ‘usual source of care’ — meaning a particular doctor’s office, clinic, or health center.” CAP also notes that “black women have experienced a reduction among those who delayed or went without care due to cost.” The ACA has increased economic security for Black women and their families by reducing medical debt, in turn improving credit scores and lowering risk of bankruptcy.

Despite gains realized under the ACA, nearly 14% of Black women remain uninsured, compared to just 8% of white women. Nearly one in five low-income Black women is uninsured, compared to nearly one in six low-income white women; and Black women in the South have the lowest rates of health insurance coverage among all Black women.

Justice Barrett and her colleagues appear poised to invalidate at least portions of the ACA, if not the entire law. Should the Court strike down the entire ACA, the consequences will be dire for women of color. Many low-income women of color attained coverage through Medicaid expansion in their states — another key feature of the law that is at risk of elimination. Moreover, women of color have higher rates of pre-existing conditions, so could face insurmountable barriers to quality health care, should insurers again be allowed to deny coverage to people with pre-existing conditions. Women of color would, in particular, face worse health outcomes should they lose access to free cervical and breast cancer screenings. And, as noted by the National Partnership for Women and Families, “increasing premiums and higher cost sharing, and soaring penalties would hit women of color harder because they already earn less due to pervasive racial and gender inequalities.”

Moreover, dismantling the ACA poses a unique threat to Black women of reproductive age. Just 86% of Black women of reproductive age have health insurance coverage, compared to 95% of Black girls and 98% of Black women age 65 and older. However, Black women die from pregnancy-related complications at three to four times the rate of white women, and the death rate for Black infants is twice that of white infants. While structural racism underlies these disparities, pregnant women who lack coverage often delay or forgo prenatal care in the first trimester, and inadequate prenatal care is associated with higher rates of infant and maternal mortality.

Finally, should the Court uphold medically unnecessary regulations on abortion clinics, as Justice Barrett has suggested, this will create a two-tiered system of abortion access — one for low-income women and one for wealthier women. Many laws regulating abortion clinics are already so onerous that compliance is nearly impossible — effectually forcing clinics to close, and requiring women to travel hundreds of miles away from home for abortion care. Women of color are the least likely group to travel for abortion care, and are, consequently, denied access to their constitutional rights at a greater rate than white women.

With so much on the line and paralyzing gridlock in Congress, citizens of all races must organize and charge their local elected officials with narrowing the health care divide that will inevitably widen under this new court. First, assuming the court does not strike down the ACA in its entirety, legislators must expand Medicaid to all eligible people, including seeking family planning waivers that provide reproductive health care services and contraception access to low-income people. Along these lines, even anti-abortion lawmakers should embrace comprehensive sex education, which can reduce unintended pregnancy rates. Further, all women deserve access to quality, supportive, and culturally competent prenatal care and birthing options — a goal that can reduce maternal and infant mortality rates, and is achievable through better state funding of holistic prenatal and birthing centers. States should also establish health equity task forces, which can identify and address the inequitable health outcomes that have been laid bare during the pandemic. There are many pathways to reducing inequitable health outcomes, and states owe a duty to their citizens to leave no stone unturned.

No matter who sits on the bench, all people deserve a health care system designed with their health and economic interest at the forefront. It is up to the American people to hold lawmakers and government officials accountable to remedy health inequities exacerbated by this court. If record organizing and voter turnouts are any indication, I believe we are up to the challenge.