In 1983, when the Department of Health and Human Services assembled the first task force to examine women’s health issues, the appointed experts made it clear that the defining challenges weren’t only related to differences between men and women but also to inequality between some women and others. One fact the panel noted in its final report was that Hispanic women died in childbirth three times as often as white women; black women died four times more frequently. “If a woman is a member of an ethnic or a cultural minority,” the report stated bluntly, “her health is at risk.”

Thirty years later, that’s still the case. A new report from the Alliance for a Just Society found that women of color in the United States still face higher barriers to accessing care and leading healthy lives. In seven states, for example, infant mortality for black women is at least twice as high as it is for white women. In nineteen states, the diabetes rate is at least 50 percent higher among Latina women than white women. In the majority of the states, women of color are uninsured at higher rates than white women.

The state-by-state examination of women’s health disparities suggests that they aren’t just historical holdovers but are exacerbated by a recent political decision: the refusal to expand Medicaid. Most of the states receiving low grades for women’s health in the Alliance report were among the twenty-one that have refused to accept federal money through the Affordable Care Act to expand their Medicaid programs. That decision stranded many people in a coverage gap—too poor to qualify for subsidies on the insurance exchanges and too wealthy to meet their state’s Medicaid eligibility criteria. As The New York Times noted last year, black Americans are disproportionately affected.

Seven of the ten states that received a failing grade in the report—which considered insurance coverage, access to care and health outcomes—rejected the expansion: Georgia, Louisiana, Mississippi, South Carolina, Oklahoma, Idaho and Texas. In all, seventeen of the twenty-one states that have refused the federal money received a C grade, or worse.

“Expanding Medicaid is the single biggest thing we can do to improve women’s health across the country,” said LeeAnn Hall, the executive director of the Alliance for a Just Society. “Where they’re having clear investments for healthcare you see clearly that there are better outcomes…. Then you see these states that consistently are underperforming and not advancing the Medicaid expansion. The stark reality of that, and the implications for women, is dramatic.”

Still, Hall noted that insuring low-income women via Medicaid is “necessary but insufficient” to close the gap. That black and Latina women are more likely to be poor than white women in the first place and therefore have more to lose from opposition to the Medicaid expansion is its own injustice. Racial barriers to economic opportunity and a lack of healthcare providers in low-income communities are two other challenges Hall noted. Health inequities between Latina women and others may also be aggravated by a broken immigration system. “We know that women who are undocumented, or have members of their family who are, are more fearful of going in and getting the care that they need,” said Hall.

The “war on women” is often described in terms of right-wing affronts to sexual and reproductive healthcare, from attempts to ensure that employers can deny birth control coverage to their workers to efforts to make abortion services impossible to access, if not overtly illegal. It’s easy to chalk up these trends to ideological discomfort with women”s sexuality. But the debate is also about which types of women should be able to make their own choices—or, in the case of Medicaid, which ones deserve care. What’s increasingly clear is that the damages of this “war” are, like illness, borne by certain women more than others.