By the time it was fully formed, the Confederacy had eleven member states: Virginia, North Carolina, South Carolina, Georgia, Florida, Alabama, Tennessee, Mississippi, Arkansas, Louisiana, Texas, and the territory that is now Oklahoma.

This, with the exception of Arkansas, is also a partial list of those states that have rejected the Medicaid expansion under the Affordable Care Act. As the New York Times points out in today’s must-read story, the direct result of this is to block millions of Americans from access to health insurance. And while Southern states don’t comprise the majority of those that aren’t expanding Medicaid, the majority of people who will suffer are poor, black, and in their borders. These are some of the most vulnerable people in the country—with terrible outcomes on most measures of well-being—and Obamacare won’t help them.

Now, you could call this a coincidence, but then you’d have to grapple with a few things. First, that these are states which—in the aftermath of the Supreme Court’s ruling on the Voting Rights Act—passed draconian voter identification laws that limit access and burden low-income blacks with onerous requirements. In North Carolina, for instance, Republicans banned paid voter registration drives, removed a week from the early voting period, eliminated flexibility in voting hours, and made it difficult for precincts to designate additional voting sites for the elderly or those with disabilities. The effects of this are so disparate as to compel action from the Justice Department, which is suing North Carolina–and Texas—for alleged racial discrimination in voting rights.

These are also states characterized by the most racially polarized voting in the country. The overwhelming majority of Republican voters in states like Mississippi and Alabama are white, and the overwhelming majority of Democratic voters in those states are black. As a recent paper found, “General Social Survey and National Election Studies data from the 1970s to the present indicate that whites residing in the old Confederacy continue to display more racial antagonism and ideological conservatism than non-Southern whites.”

The New York Times notes that conservative lawmakers “bristle” at the suggestion that race has anything to do with their rejection of the Medicaid expansion. “State Senator Giles Ward of Mississippi, a Republican, called the idea that race was a factor ‘preposterous,’ and said that with the demographics of the South—large shares of poor people and, in particular, poor blacks—’you can argue pretty much any way you want.’”

It’s impossible to know if racial animus was a factor in the South’s rejection of the Medicaid expansion. But if the Southern states have large shares of poor black people, it’s because—for the bulk of their history—they were explicitly organized to maintain black disadvantage, a fact that shapes almost everything about the region. The deep anti-government ethos of Southern conservatism, for instance, has its roots in slavery, Jim Crow, and white supremacy. The slaveholders who articulated “states’ rights” ideology in antebellum period gave way to the post-Confederates who used law and violence to maintain the white power structure. In turn, their descendants—who occupied both parties for the better part of a century—worked furiously to undermine public goods and keep federal interference to a minimum. There’s a reason, after all, that the far right of the South is also home to a variety of white nationalists and unabashed neo-Confederates.

No, this is not a convoluted way of calling Republicans racists. It is, however, a reminder that the political culture of the South is profoundly shaped by race. “Contemporary differences in political attitudes across counties in the American South trace their origins back to the influence of slavery’s prevalence more than 150 years ago,” note political scientists at the University of Rochester in a paper exploring the legacy of slavery. Race, simply put, is encoded in the politics of the South. Lawmakers can have “colorblind” motives, but there is no colorblind policy: To reject the Medicaid expansion is to disadvantage African Americans. There’s no other way around it.

This raises a disturbing question. If Medicaid is an anti-poverty measure, and if it the expansion is meant to provide an additional floor of support for low-income Americans, what happens when there’s a large racial divide in who benefits, itself a product of past racism? At The Atlantic, Ta-Nehisi Coates looks at this racial disparity and connects it to past expansions of the social safety net, which—for similar reasons—either excluded blacks or left them with fewer benefits. He writes that with Obamacare, “one can see how an ostensibly, and well intentioned, progressive and color-blind policy proposal can actually expand a wealth gap.”

With Medicaid and the Affordable Care Act, we’re set to see a concrete example of how the racist of the past still matters for the outcomes of today.