South Carolina Gov. Nikki Haley’s denunciation of the Confederate flag last week has in some ways overshadowed her refusal to act in other areas related to structural inequality, such as refusing to expand health-care access to low-income communities across the state.

Haley has decried the racist terrorist attack on Black Americans at the Emmanuel AME Church in Charleston and announced her intentions to take down the Confederate flag waving on capitol grounds. But activists and political observers in South Carolina have charged that if Haley truly supported Black South Carolinians, she would push to expand access to Medicaid.

Haley and South Carolina Republicans will reject about $12 billion in federal Medicaid expansion funds from 2014-2020, Rozalynn Goodwin, vice president for community engagement for the S.C. Hospital Association, told the Post Courier.

In 2013, nearly a quarter of Black Americans in the United States had no health insurance, compared to 14 percent of white people. Even with the Affordable Care Act (ACA), which has drastically increased the number of insured Americans, states that have opted to not expand Medicaid continue to have a massive “coverage gap”—people who don’t qualify for Medicaid but are too poor to pay for private insurance.

South Carolina has the country’s 33rd most restrictive Medicaid program. A family of three with a total annual income of $12,271 makes too much for Medicaid, and adults without children don’t qualify. An estimated 194,000 South Carolina residents fall into the coverage gap, forcing them to pay out of pocket for health-care services.

People of color make up 36 percent of the South Carolina population, but 57 percent of its uninsured.

Access to health care is a matter of life and death for many caught in the gap. Medicaid expansion in South Carolina would save the lives of 190 people every year, according to a recent White House report.

“The Columbia, South Carolina zip code has the highest incidence of diabetes-related amputations in the nation, and many of the working poor have spiraled into poor health because of lack of access” Sue Berkowitz, director of South Carolina Appleseed, a legal justice organization, told Rewire. “A lot of these cases could be avoided and quality of life could be improved if there was access to quality, affordable care.”

Despite evidence that expanding Medicaid would save lives, Haley and the state’s GOP-majority legislature have opposed the ACA and its potential for helping low-income families receive medical care.

“We will not expand Medicaid on President Obama’s watch. We will not expand Medicaid ever,” Haley said at the 2013 Conservative Political Action Conference. Haley, in her 2014 State of the State address, once again pledged to “fight Obamacare every step of the way.”

Medicaid expansion would mean cholesterol screenings for more than 23,000 state residents, according to White House projections. About 6,500 more women would gain access to a mammogram and 9,700 women would be able to access cervical cancer screenings.

There have been race-based overturns in the way South Carolina policymakers discuss the expansion of Medicaid, or any effort to improve health care in Black communities. Back in 2009, Lindsey Graham (R), the U.S. Senator from South Carolina, said Medicaid expansion was a particularly bad idea for his state because of the Black population.

“We’ve got it tough. We’re on our knees,” Graham said. “Twelve percent of our people are unemployed and 31 percent of our people are Black.”

“The reason we have such high minority poverty rate is due to historical racism,” Berkowitz said. “The fact that the southeastern states are all refusing to expand Medicaid, it’s not an accident. It’s also where voter ID law are happening, and where insensitivity to the immigrant community is greatest.”

The uphill battle toward Medicaid expansion is one that the late state Sen. Clementa Pinckney—who was killed by the right-wing gunman who fired on Emmanuel AME Church—fought for during his time in the deeply-Republican legislature. Pinckney’s colleagues eulogized him on Friday as tenaciously advocating for Medicaid expansion, demanding education funding, and fighting the GOP’s voter ID laws and discriminatory lending practices.

Haley told CBS News last week that she hopes residents of her state will come together to have a dialogue about racism and the flag.

“What we hope is that we do the things South Carolinians do, which is have the conversation, allow some thoughtful words to be exchanged, be kind about it, come together on what we’re trying to achieve and how we’re trying to do it,” she said.

But Berkowitz said that the real test will be whether Haley will open up a dialogue about Medicaid and other public benefit programs that have been cut off or restricted in the state.

“The proof is really going to be, when we’re looking at programs that will really help to improve the lives of communities of color, whether Haley will even let us have a dialogue. Don’t shut down the ability to expand Medicaid,” she said. “Close the health care gap.”