The Color of Affordable Care

N.Y. Times, Oct. 7, 2013

By Nancy Folbre

Shortly after House Republicans shut down the federal government in an effort to halt implementation of the Affordable Care Act, Sabrina Tavernise and Robert Gebeloff of The New York Times reported that many Republican-controlled states have already strangled an important feature of the legislation by denying extension of Medicaid eligibility to the working poor.

Since the federal government committed to shouldering most of the cost of such extensions, the officials running these states seem to be cutting off their own noses to spite their faces. Then again, perhaps the noses they are cutting off are not their own.

Neither Republican officials nor their most valuable constituencies need help paying for health insurance. When they say they oppose government spending what they really mean is that they oppose spending on programs like Medicaid that – unlike universal programs such as Social Security – target low-income families.

The disparate racial impact is striking: 68 percent of poor and uninsured blacks live in states that are not extending eligibility, compared with 58 percent of poor and uninsured persons in other racial categories.

The concentration of negative effects in Southern states that also represent the stronghold of Congressional opposition to the law itself is not surprising. This episode of political history fits neatly into an established line of research that shows how federal efforts to extend protections to the disadvantaged have repeatedly fallen prey to a toxic blend of racial and regional politics. From civil rights to health insurance, white political leaders from states with large numbers of African-Americans — especially but not exclusively in the South — have cast new federal protections in apocalyptic terms and mounted a powerful opposition.

In her pioneering book “The Color of Welfare,” published in 1994, the sociologist Jill Quadagno persuasively documented the race-based politics that sent the United States down a policy path very different from that of other affluent countries, blocking the federal extension of most universal social programs other than Social Security and Medicare and giving states significant control over means-tested programs targeted at the poor. This control allowed politicians in Southern states to restrict benefits for low-income families, whatever their color.

A host of academic studies have explored the impact of intersections between race and class, noting, for instance, that in states with larger black populations race becomes more salient to the politics of social provision, altering the dynamics of social and political trust. Poor whites are promised protection against labor market competition or higher taxes in return for acquiescence with policies that restrict the social safety net.

As the Stanford economist Gavin Wright shows in his new history of the Civil Rights Movement, “Sharing the Prize,” Southern whites often overestimated the costs – and underestimated the benefits – that integration would bring them.

In “Disciplining the Poor,” an analysis of welfare reforms introduced in the mid-1990s, Joe Soss, Richard C. Fording and Sanford F. Schram demonstrate that states with a large number of African-Americans (especially but not exclusively in the South) imposed particularly stringent rules on access to public cash assistance, as well as keeping benefit levels extremely low.

In “Taxing the Poor,” Katherine Newman and Rourke O’Brien show that state income and sales taxes in the South are far more regressive than those in other regions of the country, penalizing all low-income families.

Overt racism and outright discrimination now elicit strong social disapproval, but racial bias takes a more subtle, coded form. In “Why Americans Hate Welfare,” Martin Gilens documents a tendency for Americans to systematically overestimate the percentage of public welfare spending going to blacks. His content analysis of pictures accompanying stories about poverty in three major newsmagazines between 1967 and 1992 showed that the frequency with which African-Americans were depicted far exceeded their actual representation in the population.

An Associated Press survey of racial attitudes conducted immediately before the presidential election last year clearly suggests that most Americans try not to discriminate, but that racial loyalties shape their perceptions of economic benefits.

When asked if President Obama’s race affected the likelihood they would vote for him, 80 percent of respondents said no. Yet 28 percent of respondents believed that his policies had made black Americans better off, compared with only 15 percent who believed they had made white Americans better off.

I don’t know of any analysis of the president’s economic stimulus program – or any other policy – purporting to show that blacks benefited more than whites. Indeed, the comparison itself is oddly optimistic, because neither black nor white Americans outside the top 1 percent of the population have enjoyed significant increases in family income since 2009.

Respondents predisposed to believe that a black president will try to benefit blacks more than whites are likely to view the Affordable Care Act through a racial lens, which helps explain the results of a recent Pew survey showing that almost 91 percent of blacks currently approve of the law, compared with 29 percent of whites.

This approval gap overshadows the effect of factors directly relevant to eligibility for assistance. Among those with annual family incomes of less than $50,000, 50 percent currently approve of the law, compared with 38 percent of those with higher incomes (who are less likely to benefit from it).

It’s important to note that many people who don’t approve (about 17 percent, according to a recent Kaiser Foundation poll) feel the Affordable Care Act doesn’t go far enough in reforming the way we pay for health care. Further, the complexity of the legislation makes it difficult for individuals to predict its economic consequences (the Pew survey reported that only 25 percent of poll respondents said they had a very good understanding of how the law would affect them).

Controversy and confusion make it easier for politicians to prey on pre-existing prejudices that serve their own interests better than those of their least influential constituents, as became apparent in the first stage of the civil rights movement.

This movement has yet to reach its final stage. Access to affordable health insurance should be considered a civil right for everyone.

© 2013 New York Times