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Abstract

Traditionally, scholars and policymakers concerned with making improvements to health care systems and structures have focused on insurance reform. The ACA— the United States’ most recent and substantial healthcare reform—was hoped to be an intervention that would help provide equity to all Americans. Indeed, scholars and policymakers viewed increasing access to health care through insurance coverage as a victory. And yet, despite these interventions, the COVID-19 pandemic revealed a number of policy gaps that disproportionately impacted racial minorities. Specifically, racially marginalized Americans still experienced the starkest disparities in COVID-19 complications and mortality. This has left scholars and policymakers to answer why these disparities existed in an environment where there was supposed to be greater equity across demographic groups in their access to healthcare.

This Article contributes to these conversations by exploring this gap. Specifically, this Article argues that insurance reform is ill-suited to dismantle structural inequalities in health. Indeed, this Article suggests that structural racism’s impact is so profound that it may dull the impact of insurance policy. Racialized minorities that have consistently experienced de jure and de facto structural racism, decreased access to desirable social determinants of health, and poor public health infrastructure are not as equipped to weather major health crises as communities that do not have these challenges. The impact of historically discriminatory policies on minority communities set them up for public health failure and persistent health disparities. Utilizing a case study on Flint, Michigan and an original empirical study on lead exposure and COVID-19 mortality, the Article examines the relationship that structural racism has with social determinants of health, with a specific emphasis on infrastructure. To make progress on equity within the health care system, policymakers and scholars must reframe their thinking from insurance reform to more expansive viewpoints on public health policy within the United States.

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