Racism has shaped our health care policy since our very first forays into creating a social safety net.

After the widely circulated footage of primarily white police officers injuring and killing black men in jurisdictions from Baltimore to St. Louis to New York City to North Charleston, the color line is once again front and center in the American zeitgeist. FBI Director James Comey, in his speech following protests over the deaths of Michael Brown and Eric Garner, described the nation’s black/white divide this way: “A tragedy of American life—one that most citizens are able to drive around because it doesn’t touch them—is that young people in ‘those neighborhoods’ too often inherit a legacy of crime and prison.”

That’s pretty typical of how we think about America’s race problem, as a legacy that hurts people of color, one that affects whites only insomuch as they are afflicted by pangs of conscience. We also think of racism as something that goes in one direction, like a bullet from a gun. But racism has insidious effects on white people, too—especially on their health.

Americans—white and black—live shorter and sicker lives than people in 16 industrialized countries. The most recent Institute of Medicine report on life expectancy makes it clear that privilege isn’t a panacea: “Americans with healthy behaviors or those who are white, insured, college-educated, or in upper-income groups appear to be in worse health than similar groups in comparison countries.” As the IOM notes, our lack of universal access to health care plays a major role in this.

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Several American presidents have tried and failed to usher universal health care into law, including Barack Obama. His health care reform law, the Affordable Care Act , was historic because of the extent of government assistance offered and the regulations on insurance practices enacted. The law expanded Medicaid, the government insurance program once reserved for low-income families, to single adults, and created a health insurance exchange, where government subsidies helped the uninsured pay for their coverage. Twenty states have refused to accept the Medicaid expansion.

Opposition to the ACA was frenzied and described by some (including Jimmy Carter) as simple racism, a way to strike out against a black president. “The poorest states in the Union are turning down expansions of Medicaid because a black person is offering it to them,” observed historian John Bracey. Obama challenged the idea that anger at health care reforms is driven by racism in an interview with The New Yorker, though he did wryly note that “There’s no doubt that there’s some folks who just really dislike me because they don’t like the idea of a black president.”

Opposition to reform may not have been motivated solely by racism directed specifically at Obama, but it was certainly tinged with fear of a new racial social order, one where African-Americans would hold power and use it to extract revenge on whites. Rush Limbaugh described the Affordable Care Act this way: “This is a civil rights bill, this is reparations, whatever you want to call it.” After citing a number of such remarks from Limbaugh and other conservative commentators, along with several studies indicating that race was shaping opposition to the ACA, Paul Waldman, writing for the Washington Post, argued that “it would be blind to deny that race has had a role in keeping that opposition so fervid for so long.”

In fact, racism has shaped our crazy health care policy since our very first forays into creating a social safety net and is still woven into our legal and political system. Choices about race and policy in the 1930s actually set the groundwork for overturning the Medicaid mandate of the Affordable Care Act in 2012. This legacy has left millions of Americans, black and white, uninsured.

Exclusion and Compromise

The policy problems began with President Franklin Roosevelt’s New Deal, which created America’s first comprehensive federal plans for social services. The New Deal did not include a national health insurance plan, though one was seriously considered before the idea was put aside. Universal health care was scuttled because Roosevelt feared it might jeopardize the entire reform effort, which was tumultuous from beginning to end. To enact New Deal legislation, FDR had to tangle with powerful interests that included those in his own party—Southern Democrats, who did not want African-Americans getting a hand up from the government. “The South’s commitments to a hierarchical racial order,” Ira Katznelson explains in his book, Fear Itself: The New Deal and the Origins of Our Time, “affected the full range of New Deal policies and accomplishments.”

The New Deal tried to sidestep the racial divide rather than surmount it by systematically excluding African-Americans from social services, as Jill Quadagno explains in The Color of Welfare. The expansion of Social Security, for instance, excluded farmworkers and domestic laborers from benefits, jobs that were held predominantly by African-Americans. As a result, three-fifths of the African-American workforce were excluded from Social Security benefits in the South, representing more than half of the nation’s African-American workers.

As part of the efforts to sway Southern congressmen to support the New Deal, states were charged with distributing welfare and were allowed to create their own rules for eligibility. States could (and did) deny benefits to African-Americans. Jurisdictions throughout the South enacted subjective criteria like “requiring that homes of aid recipients be deemed ‘suitable,’ morally and otherwise, for rearing children,” and used them to systematically exclude African-Americans from welfare, according to political scientists Robert Lieberman and John Lapinski.

Roosevelt wasn’t the only president who, tangled in a thicket of race politics, couldn’t push through a national insurance program. President Harry Truman made two distinct calls in his 1947 State of the Union address: “We have recently witnessed in this country numerous attacks upon the constitutional rights of individual citizens as a result of racial and religious bigotry,” he said. “The will to fight these crimes should be in the hearts of every one of us.” A few beats before this, he had urged Congress to “provide adequate medical care to all who need it, not as charity but on the basis of payments made by the beneficiaries of the program.” One call eventually cancelled out the other. Despite popular support, the chance for universal health care died.

Instead, even though it had no health care component, Roosevelt’s New Deal became the blueprint for Medicare and Medicaid, the health insurance programs that the government does offer today. President Lyndon Johnson faced the same challenges as Roosevelt in enacting the antipoverty legislation that comprised his plan for a Great Society. He needed votes from Southern Democrats. Ultimately, Medicare (insurance for the elderly) and Medicaid (insurance for the poor) became a part of the Great Society and are now understood as landmarks of Johnson’s War on Poverty. But they were passed with significant compromises—the same compromises Roosevelt made with Social Security and welfare. Domestic and farm labor were excluded from Medicare, which was a federal program, while Medicaid “re-created the [welfare] compromise in the New Deal and left eligibility, benefit levels, and administration to the states,” writes political scientist Gerard Boychuk.

Medicare, which is available regardless of income, is seen as an entitlement. Medicaid, as a program for the poor only, is perceived as welfare. The singularly odd arrangement of government health insurance programs created two classes of government health insurance and still managed to cover only a fraction of uninsured Americans.

Unforeseen Consequences

Turning Medicaid over to the states also had the unforeseeable consequence of undermining insurance for the very poor that was originally part of the ACA. The ACA required states to expand Medicaid to anyone making about $16,000 a year or less. The deal was that the federal government would initially cover all costs of the expansion and after three years, it would cover 90 percent of costs. States already received a significant amount of funding from Medicaid, which comprises on average 10 percent of state budgets. The plan would have pumped health care money into poorer Southern states.

Still, the law was challenged immediately, by the poorest states, mostly in the South, which did not want to expand Medicaid, even though it was free for them to do so. Eventually the lawsuit resulted in a Supreme Court case, National Federation of Independent Business v. Sebelius, which took issue with two key provisions of the ACA, the requirement to carry insurance or pay a penalty, and the requirement for states to expand Medicaid. The court found in its majority opinion that the federal government, by threatening to take away 10 percent of states’ budgets if they refused to comply with the new Medicaid rules, was essentially compelling the states to comply in violation of their constitutional autonomy. Justice Roberts’s opinion called it “economic dragooning that leaves the States with no real option but to acquiesce in the Medicaid expansion.” And that, the court decided, was unconstitutional. The group most affected by the decision is poor white people, 46 percent of whom are now ineligible for Medicaid.

Opponents of the law weren’t satisfied with striking down the mandatory Medicaid expansion and pursued another case, King v. Burwell, which challenged the legality of government subsidies for insurance. The Supreme Court struck down the case by a majority in June, a stroke of luck for white people. If the plaintiffs prevailed, more than 60 percent of those excluded from the subsidies they needed to afford health insurance would have been white.

Attorney generals and conservative talk show hosts alone didn’t drive the furor against the ACA that propelled challenges all the way to the Supreme Court. White people, particularly those who already believed America’s core values were under attack from the ACA and those who already harbored implicit or explicit racist attitudes, across the country also drove it. Today, about 50 percent of white people still have an unfavorable view of the ACA compared to 20 percent of African-Americans.

This is just one example of what Bracey calls “the cost of racism to white people.” Racism does not just color decisions about welfare and food stamps, but it has also left an indelible mark on the policies that shape all of our lives.