The roots of inequitable distributions of health care resources

All people deserve equitable and accessible health care resources, regardless of race, ethnicity, gender, socio-economic status, immigration status, or location. The history of discrimination and oppression in the United States and the resulting systemic barriers that marginalized communities face have prevented this from becoming a reality. To advance health equity going forward, it is important to acknowledge periods of inequity and moments of progress in health care resource distribution throughout history. 
Numerous discriminatory practices have played a role in shaping the inequitable distribution of health care resources observed today—far more than can be adequately summarized in this brief format. For the following timeline, we narrowed the focus to select health-specific policies, events, and actions. 

Periods of Inequity:

• 1619-1865: The year 1619 is considered the starting point of slavery in America when colonizers first brought enslaved African people to Jamestown, Virginia. For over two centuries, enslaved African people endured horrific exploitation and inhumane treatment due to White supremacist beliefs. Slavery was finally abolished after the Civil War and the passage of the 13th Amendment, though its legacy of racism and oppression is rooted in various systems and beliefs today.
• 1865-1866: Black Codes were enacted after the Civil War in southern states to further oppress formerly enslaved people, including as unpaid or underpaid labor. The laws perpetuated discrimination and disenfranchisement of Black communities, reinforcing beliefs that they were less deserving of rights and well-being.
• 1877-1964: Jim Crow laws were enacted at the end of the Reconstruction period to enforce racial segregation in the South and thereby, further disenfranchising Black communities by denying social, economic, political, and health rights and resources from them.
• 1896: The Plessy v. Ferguson ruling upheld racial segregation by determining that the right to equal protection under the 14th Amendment can be preserved with “separate but equal” facilities. This ruling had immediate and long-term effects on Black communities’ access to quality health care, among other resources.
• 1910: The Flexner Report, funded by the American Medical Association and Carnegie Foundation, explored medical education in the U.S. and Canada. The report contributed to the closure of five of seven established medical schools that trained many Black physicians, leading to a decrease in the number of trained Black physicians available to serve Black communities.
• 1946: The Hospital Survey and Construction Act, also known as the Hill-Burton Act, provided federal funding for hospital construction but allowed for “separate but equal” facilities. This provision enforced racial segregation of publicly funded hospitals, limiting Black communities’ access to both federal funds and quality health care.
• 1950s-1970s: The “White flight” phenomenon involved the migration of White individuals from urban centers, with growing populations of people of color, to suburban areas. This migration stripped cities of wealth and tax revenue, weakening public services and limiting access to resources and care for communities of color. 

Moments of Progress:

• 1865-1960s: Black communities were denied care and Black doctors were excluded from working at most White hospitals during this period, inspiring the Black Hospital Movement. Black doctors, alongside community organizations, created Black-owned hospitals across the country to serve Black patients, increasing their access to health care and providing a space for Black doctors.
• 1954: Brown v. Board of Education overruled the “separate but equal” clause of Plessy v. Ferguson as the Supreme Court determined that segregated education facilities violated the 14th Amendment. This landmark case was a catalyst for the civil rights movement, expanding access to various resources for people of color.
• 1963: In Simkins v. Moses H. Cone Memorial Hospital, Dr. George Simkins, a well-known Black dentist, filed a lawsuit, alongside colleagues and the NAACP, against two local private hospitals receiving federal Hill-Burton funds that denied or limited access to care for Black patients. After an initial loss, an appeals court ruled that the hospitals violated the 5th and 14th Amendments, deeming “separate but equal” policies unconstitutional for hospitals receiving federal funds. This landmark case contributed to the eventual desegregation of health care facilities.
• 1964: The Civil Rights Act of 1964 was enacted to outlaw discrimination by race, color, sex, religion, or national origin, enforcing desegregation and equality in voting requirements, employment, use of public areas, and federal programs. This landmark law ended Jim Crow laws and influenced future laws, decisions, and actions regarding civil rights and discrimination, including in health care.
• 1965: Federally Qualified Health Centers, also known as Community Health Centers (CHCs), were established during the War on Poverty. CHCs are local clinics that were placed in high-poverty neighborhoods to provide affordable, comprehensive health services to low-income, underserved populations, increasing their access to care. CHCs still serve low-income communities today.
• 1965: The Social Security Amendments established Medicare, a health insurance program for elderly people, and Medicaid, a health insurance program for people with low-income. For decades, the programs have increased access to health care, with over 68 million people enrolled in Medicare and over 71 million people enrolled in Medicaid as of April 2025.
• 1970: The Title X Family Planning Program was established in the Public Health Service Act to provide grants to public and nonprofit agencies to promote family planning and prevent adverse reproductive health outcomes. Title X clinics have improved access to reproductive care for low-income women and women of color.
• 1985: The Report of the Secretary’s Task Force on Black and Minority Health, also known as the Heckler Report, was the first government-led study to examine health outcomes and disparities experienced by people of color. This landmark study asserted federal priorities to eliminate racial health disparities, inspiring the creation of the Office on Minority Health within HHS in 1986.
• 1990: The Americans with Disabilities Act (ADA) was established to provide civil rights protections and equal opportunity to people with disabilities and mandates accessible health care facilities and services.
• 1990: The Disadvantaged Minority Health Improvement Act amended the Public Health Services Act to prioritize health needs and access to health care of disadvantaged communities, including people of color. The Act authorized grants to provide health services and education to residents of public housing and to fund programs for minorities at health profession schools and scholarships for disadvantaged students.
• 1997: The Children’s Health Insurance Program (CHIP) was established under Balanced Budget Act of 1997 to provide health insurance to uninsured children in families who can’t afford private insurance but have income too high to qualify for Medicaid. CHIP expanded access to health care for many, particularly children of color. In 2009, the CHIP reauthorization law included an option in which states can provide health insurance for lawfully residing immigrant children and pregnant individuals, promoting greater access to care for a historically excluded group.
• 2010: The Patient Protection and Affordable Care Act (ACA) was enacted to increase availability of affordable health insurance, expand Medicaid for low-income adults, and support innovation in health care. The ACA particularly helped people of color receive health insurance and access health care. 

Recent Threats to Equity: 

• 2019-2023: In the U.S., marginalized communities were and continue to be disproportionately impacted by the COVID-19 pandemic, revealing the pervasion of systemic racism and discrimination and unequal access to resources.
• 2022: The Dobbs v. Jackson ruling overturned Roe v. Wade (1973) by deciding that the right to abortion is not protected under the Constitution and permitting states to enact laws to protect or restrict abortion rights and access.
• 2025: Under the new presidential administration in 2025, there have been sweeping funding cuts for several social, economic, and health programs, restricting communities’ access to essential care and services. 

This timeline provides an abbreviated snapshot of the roots of inequitable distributions of health care resources. As we continue to address the legacies of discrimination and oppression in health care and tackle new threats to health equity today, we must build upon the key milestones of progress throughout history that expanded access to health care resources for marginalized populations. Implementing equitable distribution of health care resources requires effective community engagement, cross-sector collaboration, and widespread systemic change in order to advance health equity for all.