For decades, Tina Payne’s hands moved with mechanical precision, operating machinery in a catfish processing plant in the Mississippi Delta. The grueling labor took a lasting toll on Payne’s body, leaving her with multiple injuries that eventually led to her disability.
When Payne applied for Medicaid, she expected the system she had paid into for years would be a safety net. Instead, she endured months of red tape only to receive a denial that left her both in pain and without coverage.
“It’s so hard for us to get help,” Payne said. “I feel that it’s wrong for you to go out there and work all these years, and you can’t get anything when you need it.”
She was eventually able to enroll in Medicaid after months of relying on her family and friends for help, rationing medication and skipping doctor’s appointments she could not afford.
Now 58, Payne is one of many Black Mississippians whose struggle to access Medicaid is more than a bureaucratic failure. It is part of a much older story about how the South has long denied Black people access to care, dignity and rest. Individual states and the federal government, which covers the majority of costs, jointly fund Medicaid. It is the primary government program covering health care insurance for people with limited incomes.
In the video: Lifelong Leland, Mississippi, resident Tina Payne shares her perspective on the inaccessibility of the Medicaid application. (Credit: SPLC)
Yet in states like Mississippi, which still has not expanded the program under the Affordable Care Act (ACA), many people fall into the “coverage gap.” For Black Soeutherners, this gap echoes generations of exclusion. From slavery to the present day, the health of Black communities has been exploited and neglected, even as Black bodies were used to build the foundations of modern medicine.
Payne’s story is featured in the Southern Poverty Law Center’s new report, Stepping Into the Gap: Medicaid Expansion in the Deep South as a Lifeline to Care. Published in June, the report outlines the deep-rooted disparities Black communities, especially in the South, have faced in accessing care. It also presents a clear path toward equity: expanding Medicaid.
“This didn’t happen in a vacuum,” said Gina Azito Thompson, an SPLC policy analyst and author of the report. “The Deep South — while rich in history and culture — is also home to some of the highest racial health and income disparities in the country as a direct result of the harsh living conditions, malnutrition and other forms of torture enslaved Black people endured.”
The history of racism in health care
In the report, Azito Thompson traces the structural racism embedded into the health care system to slavery, when Black people were denied autonomy over their own health. Enslaved people had no control over whether or when they could receive medical attention. Care was typically offered only when enslavers sought to protect their own economic interests.
After emancipation, Black communities faced systemic barriers to care, prompting the federal government to create the Freedmen’s Bureau in 1865. The short-lived agency provided temporary health services and other support until states were expected to take over. Although this was one of the first federal efforts to address racial health disparities, the bureau was disbanded in 1872 due to inadequate funding, racist resistance and political opposition.
Black Southerners have long been excluded from the full benefits of medical care even as their bodies were exploited to advance it. Throughout history, Black people were often subjected to involuntary medical experimentation. While some physicians were praised for the discoveries that followed, the Black people who made those advancements possible were largely forgotten.
One example is J. Marion Sims, who operated, repeatedly and without anesthesia, on enslaved Alabama women to develop gynecological techniques. Though Sims was honored with a statue and professional acclaim, the women he experimented on were largely denied recognition until 2021, when a monument was erected in Montgomery to honor the “Mothers of Gynecology” by name.
Another example is the Tuskegee syphilis study the U.S. Public Health Service launched in 1932. Hundreds of Black men in rural Alabama were misled into participating in a study on untreated syphilis. The men were never given an accurate diagnosis or offered treatment.
The study continued for decades, ending in 1972.
Many of the men, along with their wives, children and others, contracted the disease. A class action lawsuit eventually led to a settlement.
In 1994, the U.S. government issued a formal apology to surviving participants and their families.
These cases are part of a broader pattern in which Black people were exploited for medical gain while being denied its benefits. Today, Black communities still face disparities in access to care, Azito Thompson said, revealing how little has changed.
“For hundreds of years, Black people have paid the ultimate price from treatable and preventable illnesses,” Azito Thompson said.
Expanding Medicaid advances health equity
In the Deep South, where rural hospitals are closing and chronic illness rates are among the highest in the nation, Medicaid is a lifeline.
“Medicaid can change lives, but only for people who can overcome all the obstacles in accessing it,” Azito Thompson said.
Across Alabama, Florida, Georgia and Mississippi, over 1.1 million people — more than half of whom are people of color — would become eligible to enroll in Medicaid if the states expanded their programs. Medicaid expansion has narrowed the racial gap in uninsured rates by 67% between Black and white adults under 65 in participating states between 2013 and 2022.
Azito Thompson said proposed Medicaid funding cuts threaten these gains, and she urged states to act where federal leadership may falter.
“The good news is Medicaid is a solution that already exists,” she said. “It’s proven to be one of the most impactful policy tools for addressing racial disparities in health care.”
In the report, the SPLC makes these recommendations to state policymakers in the Deep South:
- Preserve existing Medicaid funding by resisting state and federal cuts.
- Expand Medicaid eligibility to cover people up to 138% of the federal poverty level — without imposing work requirements.
- Integrate Medicaid with housing support to better serve people with disabilities and low incomes.
Ultimately, Azito Thompson said, Medicaid expansion is not just a matter of policy, but of racial and economic justice.
“Medicaid is really the solution to begin to redress a lot of these harms to Black people throughout history,” she said.
People who depend on Medicaid will now face additional challenges in seeking care as significant changes are implemented as part of President Donald Trump’s “One Big Beautiful Bill” Act. The Kaiser Family Foundation estimates the law will eliminate $1 trillion in federal Medicaid spending. The spending will be cut by implementing work requirements and eliminating program eligibility to lawfully present immigrants, among other changes.
According to Congressional Budget Office projections, the changes to Medicaid and the ACA marketplaces would result in 11.8 million more people losing health insurance. These shifts come as expanded premium tax credits under the ACA are also set to lapse later this year. The bill and the expiration of enhanced subsidies could leave 17 million additional people uninsured by 2034.
Azito Thompson said policymakers should strengthen health care access and expand coverage to include more people rather than weaken an important — and possibly lifesaving — program.
“I want policymakers to realize that the Deep South is resilient,” she said. “We’re deserving, just as people in other states that have expanded Medicaid, of being able to go to the doctor and not have to endure disproportionate health outcomes just because of where we live. Preserving and expanding Medicaid is crucial to ensure that everyone can go to the doctor and get health care when they need it, not just Black people.”
Payne said she hopes that sharing her story will make policymakers and voters realize the importance of supporting programs like Medicaid.
“I would like more people to just be able to go to the doctor,” she said.
Photo at top: As Tina Payne, 58, waited to be approved for Medicaid, she spent months relying on her family and friends for help and deferring doctor’s appointments she could not afford. (Credit: Myisa Plancq-Graham)