The website 538.com has posted an essay (found here) about the great state of Alabama. Unlike most click bait-y articles that Alabamians seem to be attracted to on Al.com (i.e. What are the 11 greatest barbecue places within 30 miles of Bryant-Denny stadium?) but instead an in-depth look at healthcare in Greene County, Alabama. Greene county is currently the least populated Alabama county (9,045 people, 81.5% black or African American). In 1860, the county had about 30,000 people. Well, kinda depends on your definition. 23,598 of those “people” were actually enslaved human beings. Although the math works out to approximately 4 enslaved humans for every 1 “person,” in fact it was almost 7000 enslaved humans were owned by about 50 folks. As described in the Encyclopedia of Alabama, this was not a bad thing

In the decades leading up to the Civil War, Eutaw experienced a golden era as the mercantile and legal center of the Black Belt. The first courthouse, built in 1838, burned in 1868. The current courthouse was built in 1993.

The county is in a region of the state known as the “black belt”, named not for the color of the population but for the color of the soil. The slow slide to economic despair over the last 150 years has taken a toll on the region. Immediately after the civil war, the region was home to 40% of the “citizens” of Alabama. The systematic oppression of former slaves and the descendants of former slaves has lead to the growth and development of many civil rights leaders, blues musicians, and story tellers. It has also lead to a bunch of people moving away. The region, once the economic engine for the region, is now home to 12% of Alabama’s population. In the words of one Percy County resident

“The only reason people come to town now is for funerals, and they leave as soon as they’re over ’cause there’s nothing to do and nowhere to stay,” said Walker, 64, the son of sharecroppers

For those who have stayed, economic prosperity has been an uneven proposition. The racial makeup of the Black Belt region was 52.2% African American, 45.8% White, 0.2% Native American.

The poverty rate among [Wilcox] county’s white population is just 8.8 percent, which is lower than all but five counties. The poverty rate among the county’s much larger black population is 50.2 percent. The 41.4 percentage point gap is the largest in the state.

Other Black Belt counties have a similar dynamic. Lowndes County has a 4.1 percent white poverty rate – the lowest in the state – but a 34.5 percent black poverty rate. In Perry County, the white poverty rate is 8.1 percent, while the black poverty rate is 32.7 percent. In Marengo County, it is 5.6 percent and 40.8 percent respectively.

So why worry about these folks? Can’t they continue to vote with their feet?

“The Black Belt is a road map,” said Patrick Sullivan, a professor at the Rollins School of Public Health at Emory University who previously worked on HIV surveillance at the Centers for Disease Control and Prevention. “That’s what’s so tragic and so compelling. It’s an endgame depiction of what happens when you have social and structural inequalities. It’s the vestiges of slavery and inequality, and in the long run those things do play out as health inequalities.” Sullivan and colleagues have studied why HIV rates are so much higher among African-Americans and Latinos than other racial groups3 and found that health insurance is the most important mediating factor. People in both racial/ethnic groups are more likely to be poor and have less education, which are related barriers, but insurance coverage is where the local and federal government could improve access to treatment, Sullivan said.

Alabama is not a Medicaid expansion state. Our Doctor-Felon-Former-Governor decided it was a political chance he did not want to take, even after his re-election into a term limited position. Remember, adults who are employed but make less that 138% of poverty uninsured are not eligible for Obamacare. In counties like Greene, where 40% of the population is below the poverty level, that is a lot of folks, almost all of them black. When the median household income is $20,000, people are going to choose food when having to decide regarding food vs insurance, every time. So what is the right thing to do? In the words of my friend and colleague John Waits, quoted in the article:

“Nothing happens without Medicaid,” Waits said. “It is the No. 1, the No. 2, it is the top 10 solutions.”

I’m beginning to think this is about something other than partisan politics.

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