Forgot Your Password?

New to The Nation? Subscribe

Print subscriber? Activate your online access

.nation-small__b{fill:#fff;}

Why Black People Can’t Earn Our Way Out of Racism in Maternal Care: A Q&A With Khiara Bridges

In her new book, Bridges found that healthcare provided through private markets leaves more room for discrimination and unequal care to take root than in a public program like Medicaid.

Khiara M. Bridges’s newest book, Expecting Inequity, “has been a long time coming,” the UC Berkeley law professor told The Nation in early March. Bridges, who earned a PhD in anthropology at Columbia University, where she also received her JD, first studied the roles of class and race in maternal healthcare in her 2011 book Reproducing Race, offering what she now calls a “scathing critique of Medicaid and its program of prenatal care…that completely disregards the desires of the pregnant person and also completely disregards the discretion of the provider,” especially compared with people who receive commercial insurance and can make a lot more choices about their care. This system treats the poor, she wrote, as a “fictional uniform population” and erases their unique desires and needs, undermining their agency while allowing inequality, and racial inequality in particular, to continue unabated. But people attending her book talks questioned whether the dehumanization that low-income people of color experience is really due to their race or primarily a function of their poverty. They were right, Bridges says, that poor people in the United States are treated unjustly. “But implicit in that question was the assumption that racism doesn’t show up when you have class privilege—that you [can] escape dehumanization and negative outcomes if you are a person of color with some degree of wealth or affluence.” Expecting Inequity is Bridges’s investigation into whether that is possible.

The answers are surprising. As Bridges was reviewing CDC data on pregnancy-related deaths, she noticed, as she writes in her new book, that while “black people with less than a high school education are 1.8 times as likely as white people with less than a high school education to die from a pregnancy-related cause…black people with a college education or more were 5.2 times as likely as white people with a college education or more to die from a pregnancy-related cause.” In other words, the disparity in maternal mortality rates between educated Black people and their educated white counterparts is greater than the disparity between uneducated Black people and their uneducated white counterparts.

The result of two years of investigation, Expecting Inequity exposes structural inequities within the healthcare system that are inescapable no matter your income or wealth. Bridges conducted studies at two San Francisco hospitals—Golden Health, a world-renowned private hospital, and the nearby “poor people’s hospital,” the Zuckerberg San Francisco General Hospital—and interviewing 200 pregnant or newly postpartum people, including 75 “unicorns” or class-privileged Black people, residing in San Francisco. She found that when the healthcare is provided through private markets—as it is in commercial insurance programs—there’s more room for racism and unequal care to take root. While Black people with class privilege can access a higher tier of healthcare than the Medicaid system, which comes with standards and regulations that overemphasize the medicalization of pregnancy, the lack of government oversight of the “profit-maximizing, discretion-packed processes found in the profit-generating side” is leaving “socioeconomically fortunate black people susceptible to race-based harm.” Meaning that, for example, their concerns about life-threatening conditions may be dismissed as they are subjected to anti-Black discrimination due to racist assumptions and stereotypes made by providers. As Bridges says, Black people are not able to earn or educate our way out of anti-Blackness. Still, in our conversation, Bridges discussed why she remains hopeful about the United States getting this right. This interview has been edited for length and clarity.

Regina Mahone: In explaining why maternal and infant health disparities are starker for people with commercial insurance—who are, on average, higher-income—than for those who are on Medicaid, you write that “Medicaid delivers a uniform program of prenatal care for the poor…. While this standardization problematically limits patient and provider autonomy, it also reduces racial disparities in infant and maternal mortality. In doing so, Medicaid serves antiracist goals.” Can you talk more about this finding and how, as you say, Medicaid makes “race matter just a little less” when we look at infant and maternal mortality data?

Khiara Bridges: I’m so fascinated by contradictions, and that was one of the contradictions that motivates this project. When I was researching this book, the contradiction became apparent: The rates at which Black and white pregnant folks [on Medicaid], as well as the babies that they birth, die are actually closer than the rates at which Black babies and Black parents and their white counterparts die when there is class privilege. So the gaps are actually higher at the higher end of the socioeconomic ladder. The critiques that I made in Reproducing Race about Medicaid are valid critiques, but how do I reconcile that with the fact that these features that one ought to criticize are actually producing outcomes that are more racially equitable than what we see with regard to the commercially insured? It is the program of prenatal care that one can’t opt out of—Medicaid—that reduces the racial disparities in maternal and infant mortality and morbidity. The question that I ask in the book is, given that fact, what does racial justice look like? Should we be fighting for Medicaid for all, even though that means that we will be denied choices around what care to receive and who to receive it from and what procedures to undergo? I don’t resolve this tension in the book, but it’s a question that we need to ask ourselves. If we are fighting for a world in which one’s ability to survive does not depend on one’s race, what sort of institutions should we produce? And it seems like when we’re talking about maternal and infant mortality and morbidity, we need to be thinking about the universal healthcare that removes some of the discretion that providers make in our current kind of regime.

RM: You write about how the healthcare system is profoundly segregated, but not only that: The hospitals that primarily serve uninsured patients or patients receiving Medicaid make it possible for hospitals that serve class-privileged patients to offer superior care. You draw a parallel between healthcare and housing, and how redlining and other forms of housing discrimination have made it possible for wealthier neighborhoods to exist. Why was it important to you to make those connections and the observation that, in general, “poor people make it possible for wealthier people to have nice things”?

KB: One of the things that I wanted to do with this book was to denormalize the fact that there are poor people’s hospitals and hospitals for everybody else. People in the US tend to think that it is just normal and natural for there to be institutions for poor people and institutions for nonpoor people. We........

© The Nation