As the United States approaches its 250th anniversary, the nation is reflecting on its identity as the land of opportunity and a global leader in innovation across sectors. Yet, this milestone arrives at a moment of profound reckoning, as the country remains in the midst of a healthcare crisis, with Black America continuing to bear the heaviest burden regarding inequities in health care.
We live in a country that leads the world in medical innovation, but access to that innovation remains deeply unequal. While we debate healthcare policy, families are forced to make impossible choices between life-saving medicines and basic, everyday necessities.
When systems built to serve the nation fall short, they fail everyone – but they fail vulnerable populations first and worst. So, as we commemorate 250 years of American progress, we must confront these inequities and recommit to making opportunity, including access to quality healthcare.
A Kaiser Family Foundation survey found that more than four in ten American adults struggle to pay for healthcare costs. That figure climbs to 49% among Black Americans. The consequences are not abstract: people delay care, skip doses, forgo screenings, and put off treatment until a manageable condition becomes a crisis. This is not a failure of individual responsibility. It is a failure of policy and commitment.
What makes this moment so consequential is that we are not without resources or solutions. We have programs on the books that were designed specifically to address these disparities. We have access to health information like never before. The problem is that too many of those programs have been captured by the very interests they were meant to counterbalance.
Consider the 340B Drug Pricing Program. Created by Congress in 1992, the 340B program was built on a clear premise: helping low-income and other vulnerable patients access more affordable medicines. The program allows eligible healthcare organizations that serve large numbers of underserved patients to purchase outpatient prescription drugs at significant discounts. These savings are intended to help providers reinvest in patient care and protect access to life-changing therapies for the communities that need them most.
Hospital consolidation is another factor here. Hospital consolidation has steadily eroded healthcare access by reducing competition, driving up costs, and concentrating services farther from the communities that need them most. As hospitals merge into expansive systems, facilities in historically Black and underserved neighborhoods are more likely to be closed, downsized, or stripped of essential services, forcing patients to travel farther and wait longer for care. Rather than improving efficiency or outcomes, consolidation often narrows patient choice and reinforces longstanding racial inequities in access and health outcomes.
These dynamics were powerfully illustrated by the late Congressman Donald McEachin, who raised alarms about Bon Secours’ disinvestment in Richmond Community Hospital – located in a predominantly Black neighborhood – while resources and enhanced services flowed to more affluent areas within the same health system. McEachin warned that declining patient volume was being mischaracterized as a lack of need, rather than recognized as evidence of structural barriers to access, and argued that consolidation in this context functioned as a “reverse Robin Hood,” extracting value from vulnerable communities instead of serving them. Rather than improving efficiency or outcomes, consolidation often narrows patient choice and reinforces longstanding racial inequities in access and health outcomes.
These harms are compounded by the way consolidation intersects with the 340B program, and the way the program has drifted from its founding mission. Without meaningful oversight or transparency requirements, large hospital systems and major chain pharmacies have transformed a public good into a private windfall. Hospitals are purchasing drugs at steep, legally mandated discounts and then selling them at full price or sometimes even more to patients – with no federal requirement that the savings be directed toward low-income populations, and often no requirement to report how those funds are used at all.
What we do know is troubling. Research shows that the majority of hospitals participating in 340B provide less charity care than the national average, even as they generate significant revenue through the program. The National Consumers League found that 340B hospitals are often more aggressive than their non-340B counterparts in pursuing patients for medical debt — garnishing wages, placing liens on homes, and filing lawsuits against people who simply cannot pay.
Meanwhile, hospitals are allowed to extend their 340B footprint by operating "child site" facilities in off-campus locations, which are increasingly clustered in higher-income areas rather than the underserved neighborhoods the program was designed to support. Similarly, research published in JAMA Health Forum found that the number of 340B contract pharmacies in predominantly Black, Hispanic, and low-income areas declined, even as the number of these 340B contract pharmacies grew in wealthier communities.
Together, hospital consolidation and the unchecked misuse of 340B have shifted resources away from the very populations the healthcare system is meant to protect—deepening inequities and undermining access to care for Black communities.
This is the policy environment we must change. And it is precisely where the urgent and critical work of advocates matters most.
Congress must enact targeted, common-sense reforms to restore the 340B program to its original intent. That means requiring all 340B participants to provide reduced-price drugs on a sliding fee scale to low-income and uninsured patients. It means mandated, detailed public reporting on how 340B savings are being used. And it means placing meaningful limits on how large corporate pharmacy chains and pharmacy benefit managers can participate in the program without demonstrably serving vulnerable populations.
Health equity is achievable, but it will not happen on its own. It requires a clear-eyed diagnosis of how current policy is falling short, the political will to demand accountability, and an organized advocacy movement that refuses to accept a system that extracts wealth from the most vulnerable while weakening the safety net it should be strengthening. Black America — and all Americans — must speak up and work together now to make health equity a reality in the United States.