The Racial Divide in State Medicaid Expansions

Abstract

This study considers five important questions related to the role of race in state-level public support for the Medicaid expansion: (1) whether public support for the Medicaid expansion varies across the American states; (2) whether public support is positively related to state adoption; (3) whether this support is racialized; (4) whether, if racialized, there is evidence of more state responsiveness to white support than to nonwhite (black and/or Latino) support; and (5) does the size of the nonwhite population matter more when white support is relatively low? Our findings suggest that while public support for the Medicaid expansion is high at the state level, especially in comparison to public support for the ACA, there are important variations across the states. Although overall public support is positively related to state adoption, we find that public support for the Medicaid expansion is racialized in two ways. First, there are large differences in support levels by race; and second, state adoption decisions are positively related to white opinion and do not respond to nonwhite support levels. Most importantly, there is evidence that when the size of the black population increases and white support levels are relatively low, the state is significantly less likely to expand the Medicaid program. Our discussion highlights the democratic deficits and racial bias at the state level around this important coverage policy.

Unequal Higher Education in the United States: Growing Participation and Shrinking Opportunities

“…Indeed, there is some precedent for such practices. U.S. states with larger Black populations were less likely to accept generous federal subsidies to expand Medicaid, a health insurance program for low-income residents, suggesting that some politicians would rather refuse resources than see those funds benefit Black Americans (Grogan and Park 2017). It does not take a great leap of logic to imagine the politics of higher education following a similar path.…”

Policy Feedback and the Politics of the Affordable Care Act

“…This “welfarization” of Medicaid points to the impact of race on the program’s politics, a situation related to the fact that only 43 percent of Medicaid beneficiaries are white, compared to 81 percent for Medicare and 83 percent for Social Security (Michener, ). As Grogan and Park () note, consistent with theories of racial policy backlash, states with large black populations were significantly less likely to adopt the Medicaid expansion, especially when white support for Medicaid expansion was low. On the other hand, illustrating the importance of partisan control, Louisiana did proceed with the Medicaid expansion when John Bel Edwards, a Democrat, won the state’s gubernatorial context and took office in January 2016, with the state’s bureaucrats then committing to signing up eligible individuals (Cohn, )…”

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“…The most important implications for a state-level analysis are using the patterns to make connections between changes to social policy and health outcome changes over time. States pursue varying approaches to an array of relevant programs and laws including tobacco control, 13 Medicare coverage, 14 hand-gun violence, 15 and nutrition. 16 These presumably affect health and longevity, and can have especially important impacts on racial differences when the policies are targeted to disadvantaged groups or outcomes that differentially affect blacks.…”