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Tea Party Politics and Health Care Reform: How a small minority is holding the majority hostage

Cartoon by Dan Wasserman, posted in Boston Globe http://b.globe.com/GU0eDm

Cartoon by Dan Wasserman, posted in Boston Globe http://b.globe.com/GU0eDm

The recent government shutdown that was precipitated by the House Republicans’ inability to accept the Affordable Care Act (ACA) as the legitimate law of the land has brought the stark political divisions in this country to a new zenith. The willingness of Republicans to hold the nation hostage to its unreasonable demands speaks to the its desperation in light of one ugly truth that they don’t want the average voter to understand: Once the ACA is implemented, the public will start to accept it, nay even like it, setting the country on a path towards more comprehensive coverage that will be increasingly hard to reverse.

Why will the public come to like the plan? In spite of its many inadequacies, the major achievement of the ACA was to bring (more) affordable coverage to millions of Americans, including hard working, tax paying Americans, who currently find health insurance unaffordable. One means of achieving affordable coverage was through expanding Medicaid coverage, a program that provides basic health insurance to qualifying low-income individuals by making anyone who earns below 138% of the Federal Poverty Level eligible for the program.

Historically, only children, pregnant women and parents have been eligible for Medicaid and only a handful of states have had programs allowing non-parents and the working poor to be part of Medicaid. As a program administered by the states, eligibility criteria and benefit packages vary widely with wealthier Northern states being much more generous than poor Southern states. The ACA was designed to make anyone below a certain income threshold, regardless of whether they are parents, working, etc., eligible for Medicaid.

However, in May of last year, the Supreme Court ruled that the Medicaid expansion, which would have initially been fully paid for by the Federal Government, was overly coercive of states thereby making the expansion effectively optional. Currently, 26 states are still undecided or have said no to expanding Medicaid. An analysis of census data by the New York Times found that as a result of not expanding the program, more than 8 million of the poorest Americans, who would have been eligible for Medicaid now will not be, and furthermore they will not be eligible for subsidies under the new health care law because their incomes are too low.

A recent New York Times article put the issue in stark terms: The states rejecting the expansion of Medicaid are the ones that already make it the hardest for poor people to get insured. Why? Most of these states, which are mainly in the South and Midwest,  are controlled by either a Republican legislature or governor.  These states present a political paradox- disproportionately poor with the highest health needs and yet with the skimpiest benefits to help the poor.

This begs the question so often asked about the US politics: Why do the poor vote against their own interests?

One explanation is simply that the poor in the South suffer from false consciousness having been swayed by populist tea party rhetoric against big government and wasteful public spending. However, recent evidence from opinion polls on the Medicaid expansion from the Deep South contradict this interpretation and instead suggest that a grave mal-representation of popular support for the Medicaid expansion may be afoot.

A recent poll by the Joint Center for Political and Economic Studies found that a wide majority of the public in five states in the deep South do support the Medicaid expansion. This includes a majority at almost all income levels and a narrow majority of whites.  When a more detailed question is asked, a large majority still support expanding Medicaid over keeping it as it is or scaling it back. Of the five states polled (Georgia, South Caroline, Alabama, Mississippi, and Louisiana), none are expanding their Medicaid programs and each has a Republican Governor that is against the expansion. These same states have elected a disproportionate share of Tea Party representatives to Congress, who are responsible for plunging the country into a government shutdown over Obamacare.

These findings suggest a deep democratic deficit in these states. Elected officials are not representing the will of the public. More research is required to understand the roots of this democratic deficit- e.g., is it driven primarily by low voter turn-out, the U.S. primary process, redistricting, the two party system, campaign finance laws (e.g., the mass political engineering of the Koch brothers) etc.

Either way, as the Medicaid expansion continues apace in the 25 states that are moving forward, one hopeful potential outcome could be a rebellion of poor and moderate income voters in states that are not expanding Medicaid to “throw the rascals out.”

Only time (and elections) will tell, but the frenzied nature with which the Republicans are trying to forestall the inevitable suggests that they have a sense of how much is at stake politically if the ACA goes forward as planned and their constituents realize what they are missing out on.

Cartoon by Dan Wasserman, posted in the Boston Globe http://b.globe.com/GU0eDm

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About Ashley Fox

Ashley Fox, Ph.D., is an Assistant Professor at the Mount Sinai School of Medicine, Department of Health Evidence and Policy. Learn more about Ashley here.

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