Sunday, February 8, 2015

Medicaid expansion and uncovered lives: are people meaner in the South?

I have lived in a number of places, from New York City to Texas, Illinois to Kansas. Politically and socially there are very different norms that prevail, which are demonstrated by the difference in who we elect and what policies we choose to legislate. And, yet, in all of these places people are people. They can be kind and generous or mean and selfish. As individuals, they love and care for their children, or sometimes don’t. They are respectful of others, or not. In all places. And yet it is clear that there are major regional tendencies to policy that must reflect the local and regional values even though people are not necessarily nicer or meaner. I think that my blog posts have made clear my positions on many issues, particularly those related to health and to social justice.

Obviously, self-interest has a lot to do with what people believe, what policies they support, and which politicians they vote for to implement those policies. To a large degree, it is economic – what is good for me and my family, as illustrated in the old Clinton campaign mantra “It’s the economy [stupid]”. Of course there is more than that. If people voted mostly for their economic self-interest, we would have a very different set of national policies because there are so many more poor and middle-class people than rich, and in the last decade especially so many more middle-class people descending toward poor than ascending toward rich. Many of the policies we have would only be supported by those who are both rich and selfish, the latter being only a portion of the rich. And yet, so many of our policies only benefit the very richest. When it is “the economy”, it is usually good for the wealthy and big business, but not necessarily for all of us. And it is more so in some states and regions. We are, not individually but as a group, meaner some parts of the country than in others.

Access to health care and the means to be healthy (having the opportunity to have a home, and good food and a job and a reasonable opportunity to care for the needs of yourself and your family) is one important arena in which we are meaner in some places than others. We know, for example, that expansion of Medicaid under the Affordable Care Act has varied not only by state but largely by region. Since the ACA intended people under 133% of poverty to be covered by this expanded Medicaid (paid by the federal government, 100% for 4 years and then 90%), they are not eligible for health insurance exchanges. Thus, if their state did not expand Medicaid, they are unable to get coverage. This is the map of states that have expanded Medicaid; clearly, it there is a strong regional difference:

This figure from the Kaiser Family Foundation, showing the regional focus of non-expansion of Medicaid in the Southeast, South Central, Plains and Mountain states, is included in a very interesting piece in the Huffington Post by Harold Pollack of the University of Chicago, “Martin Luther King wouldn’t be very happy with this map”, posted on King’s Birthday holiday, January 19, this year. What he is referring to is that the South, the area King was from and spent most of his time working in (much of which is shown in the movie “Selma”) is one of the areas most affected. But Pollack makes the point that it is actually much worse, and that the South has the vast majority of uncovered people because some of those geographically-large Mountain and Plains states haven’t got very many people. Other states that have not expanded Medicaid, like Wisconsin, have other programs covering a large number of those who would be eligible for an expanded Medicaid. We have seen maps of the US re-drawn to make the size of states proportional to their population, where California and Texas and Florida and New York are huge, and Mountain states tiny. Pollack asked Harvard researcher Laura Yasaitas to show the states re-drawn to have their size proportional to the number of uncovered people. The results are even more amazing:

Because of their larger population, Southern states now obviously account for the vast majority of uncovered people, with the most populous states – Texas, Florida, Georgia, and North Carolina seeming huge. The two states Kansas City borders, Kansas and Missouri, are pretty big (Missouri is the one above Arkansas, the blue keystone in the middle, and Kansas is to its west, over Oklahoma which is recognizable because of its panhandle). Montana, Wyoming, and Utah fade not because they are covering people but because of their small populations. California and New York only show up because the mapmakers artificially pretended there were a couple of thousand uncovered people so they wouldn’t drop off the map altogether.

As Pollack points out, the two states that have benefited the most in terms of fewer people being uninsured are Arkansas, the keystone mentioned above, and Kentucky, the dark blue state above and to its east. This is because these two, southern/border states, had very large proportions of uninsured as did the rest of the South, so showed the greatest increase in covered people when they expanded Medicaid. Arkansas’ expansion created poignant stories in places like Texarkana where the poor folks in the Arkansas half were now able to get coverage, while those in the Texas half were not (see the NY Times In Texarkana, uninsured and on the wrong side of the state line”, June 8, 2014). The lesson is that Medicaid expansion could benefit even more people if it were implemented in these large-population states, with real significant changes in the actual and potential health status of lower-income people there.

But they haven’t done it and are unlikely to. The political will is not present. There are anti-ACA crusaders in many states, but they are particularly prominent in the South, which already has the highest proportion of poor and needy people and the lowest levels of social services. Clearly, this has a lot to do with race – that historically and in the present many of the poorest people in the South are African-American (and, especially in Texas, Latino). This makes Dr. Pollack’s invocation of Dr. King particularly relevant. And particularly poignant. Racism has been one of the dominant themes in America, and while it certainly exists in all parts of the country, it has never been as institutionalized as in the South (remember slavery? Jim Crow?). And to those who say it is not like that anymore, we don’t have Bull Connor, or the bridge in Selma anymore, we are the New South, look at the map above.

I really don’t think that the people in the South, any more than in Kansas or Missouri—or Montana and Wyoming—are meaner than they are in other parts of the country. So why do they elect people who institute policies to make it look like they are?

1 comment:

Bobby Cohen said...

If meanness doesn't explain the rejection of Medicaid expansion by Southern states, what does?

Expanding your graphic analysis, I would suggest, as many have before, that you overlay the Medicaid Expansion map on the 1931 Tuskegee Institute map of lynchings in America (

Cringing at the congruence might suggest an aspect of the answer.


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