The Politics of Medicaid Policy and Racial Justice
By Jamila Michener (@povertyscholar)
Medicaid is a federal-state program that provides health insurance to low-income Americans. Most people do not immediately think about racial justice when they hear about Medicaid, but that is precisely what it is about. Astute observers have pointed out critical connections between the two and advocates working in communities of color understand the linkage. Still, Medicaid and racial justice are too often discussed as though they are separate and barely overlapping phenomena. Even when considered together, the political mechanisms linking Medicaid to racial justice tend to be overlooked or underspecified. Now, with key elections where Medicaid has been front and center—in places like Louisiana, Mississippi and North Carolina—it is more important than ever to clearly delineate the politics that tether Medicaid to racial justice.
Here are two facts that may first appear only tenuously related but are indeed deeply intertwined. First, Medicaid policy is racialized. Second, Medicaid matters for the quality of American democracy. Because Medicaid has striking racial disproportionalities and it affects numerous forms of political action, the prospects for racial justice in the United States—a goal that demands both material and political equality— are tied up with the fate and trajectory of Medicaid. This is especially true in the South, where Medicaid and race are practically inextricable.
In both Louisiana and Mississippi, a majority of non-elderly Medicaid beneficiaries are Black (52 percent and 61 percent, respectively). In North Carolina, Blacks and Latinos combine to make up 50 percent of beneficiaries. In these and other places, the racial dynamics of Medicaid are even more acute than the numbers suggest because ordinary people (non-experts) overestimate the presence of Black people on public assistance rolls.
Such racial disproportionalities create political inequalities because Medicaid affects politics. In the last two years, study after study has shown that Medicaid expansion positively affects voting (see the Data for Progress Missing Medicaid Millions report) drawing people into the electorate. Even beyond voting, my own research shows that positive experiences with Medicaid can be boost political participation, while negative experiences can demobilize and disempower Medicaid beneficiaries. The upshot of this is that many of the states where Medicaid is most stingy or where it is administered in the most stigmatizing ways are also states where large numbers of people of color live. As a result, the democratic deficits produced by Medicaid retrenchment are disproportionately borne by Black and Latino Americans, fueling political inequality through a kind of political alienation rooted in negative experiences with public policy.
Perhaps most ironically, in the very places where Medicaid policy is most likely to disempower Black and Latino voters, those voters are the lynchpin of progressive electoral coalitions, especially in the South. In Alabama, Georgia, Louisiana and Mississippi — Black Americans are the fastest-growing group of voting-age residents. As such, any policy that causes them to be politically disaffected, undermines democracy.
This is but one reason why Medicaid expansion is such a hot button political issue. To be clear, ensuring that all Americans have access to healthcare should not be a partisan matter. Nevertheless, in a context where it is treated as such, the political consequences of a program like Medicaid are not something we can afford to ignore. As we head towards a deadlocked gubernatorial election in Louisiana, this is all more clear than ever.
On November 16th, the incumbent Democrat, John Bel Edwards will face off against his Republican opponent, Eddie Rispone. Rispone is a businessman who has never held public office. His neophyte status notwithstanding, Rispone’s campaign has been buoyed by the zealous support of another businessman who catapulted into politics without any electoral experience: Donald Trump. Despite Trump’s claims to the contrary, John Bel Edwards is no “radical liberal.” Edwards’ positions on issues like gun control and abortion belie such a label. But even as a so-called “conservative Democrat” floating in a vast sea of Louisiana Republicans, Edwards has dramatically changed the state’s healthcare landscape by embracing Medicaid expansion, a core component of the Affordable Care Act. The expansion of Medicaid was spearheaded by Governor Edwards when he took office in 2016. As a result, over 445,000 additional Louisianans now have health insurance, and the state boasts historically low uninsured rates. Medicaid covers 1 in 5 adult Louisianans, 1 in 2 children living in the state, and 3 in 4 nursing home residents.
The tangible benefits that Medicaid expansion has created in the lives of people in Louisiana are massive and can hardly be overstated. According to the Louisiana Department of Health, nearly 24,000 people have received in-patient mental health care, over 19,000 have received treatment for substance use and just under 14,000 cases of colon cancer have been averted through early detection. Even beyond these concrete health gains, the entire state has experienced an economic boost on account of the infusion of Medicaid dollars, which have spurred $3.5 billion in economic activity and helped to create 19,000 jobs.
Despite all of this, Governor Edwards faces a Republican challenger who promises to “freeze” Medicaid enrollment. Ignoring the lives saved through access to medical care and the profound need for such access among vulnerable Louisianans, Rispone— one of Louisiana’s wealthiest residents—has instead focused on grossly overstated and hyperbolic claims of Medicaid misuse and fraud. In the face of a largely successful policy like Medicaid expansion, it is no surprise that Rispone would trot out trope of fraud. In doing so (even if implicitly or inadvertently), he draws from a deep and frequently tapped well of racialized stereotypes about underserving poor black people taking advantage of government largesse. Racialized divides in support for Medicaid expansion have proven politically consequential , and Rispone is leveraging such rifts to his advantage. In doing so, he is upending the will and preferences of Louisianans. Data for Progress polling shows that 61 percent of Louisiana voters support Medicaid expansion. Instead of aiming to continue a successful policy that has helped hundreds of thousands of state residents, Rispone is pushing racialized stereotypes about fraud to justify eroding Medicaid.
If Rispone wins, the “freeze” that he promises to bring to Medicaid will likely produce negative feedback loops between Medicaid policy and politics in Louisiana. Because a majority of Medicaid beneficiaries in Louisiana are Black, Rispone’s policy approach would disproportionately disempower the very people at the losing end of the popular stereotypes he has activated as an electoral strategy.
But another possibility looms large. Edwards may win. If he does, it is widely believed that his victory will be spurred on by Black turnout. In this way, Edwards’ re-election would reflect the empowerment of the very group that has largely benefitted (both materially and politically) from his decision to expand Medicaid.
The contrast of this choice is stark. Partisanship notwithstanding, it is a contest between an incumbent whose actions (in the health policy realm) have supported a more equitable, expanded electorate and an opponent who promises to take action that predictably diminishes the electorate (and does so to the particular detriment of Black voters).
Perhaps most importantly, these dynamics matter for everyone (not only Black people) and go beyond Medicaid. When candidates like Rispone exploit racial cleavages and demobilize voters of color, it is usually in an effort to make an end-run around policies that a majority of their would-be constituents actually prefer. Like Medicaid expansion, majorities Louisiana voters support criminal justice reform, a $15 minimum wage, and allowing government to negotiate pharma prices. Instead of having to contend with these “liberal” preferences, politicians like Rispone rely on the toxic intersections between racism and partisanship to mask their unpopular political opinions.
Medicaid policy is racialized. Economic policies are racialized. Criminal justice policies are racialized. Recognizing the racial dynamics that constrain progress in each of these arenas, and pursuing racial justice in each one, is the most promising and democracy-enhancing path on offer.
For further Medicaid analysis, see our memo on The Missing Medicaid Millions and our polling on Medicaid Expansion in Louisiana
Jamila Michener (@povertyscholar) is an assistant professor of Government at Cornell University. She is author of Fragmented Democracy: Medicaid, Federalism and Unequal Politics (Cambridge University Press).