The Affordable Care Act (a.k.a. "Obamacare") and the Reverse Income Effect

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The Medicaid Expansion Under the Affordable Care Act

The Affordable Care Act, passed in 2010 and initially referred to as "Obamacare" by opponents, sought to expand healthcare access by regulating the healthcare insurance industry and lowering costs of healthcare and heath insurance premiums for consumers.  With the overlapping goals of covering more people and lowering the cost of healthcare, the ACA required states to expand Medicaid eligibility requirements to allow for more individuals to qualify for Medicaid.  Medicaid provides health insurance coverage at no cost for low income families with children.  Medicaid is funded by general tax revenues that are given to the states who administer the Medicaid program.  The ACA required states to expand coverage of Medicaid or else face loss of Medicaid funds altogether.  The U.S. Supreme Court ruled in 2012 that the provision in the ACA requiring states to expand their Medicaid coverage or else lose Medicaid funds was too "coercive".  Despite the promise of the federal government to cover 93-100% of the cost of covering additional people, many conservative states, in ideological and partisan opposition to the law and President Obama, declined the expansion. This is how we get to the current patchwork of expanded Medicaid coverage across the country today.  These states argue that the state cannot afford the expansion and does not support the greater role of the federal government in healthcare.  The map above shows which states have accepted the federal funding to expand Medicaid eligibility and which states have rejected the funds and expansion. The link below from Kaiser provides a more detailed description state by state.

Kaiser Family Foundation link providing state by state status on Medicaid expansion

Without the expansion limited groups qualify for Medicaid.  Of course, there is an income limit, but what most may not know is that, under the past Medicaid eligibility rules and the current rules of states that declined the expansion, only very low income individuals that have children, individuals that qualify for disability under extreme financial hardship, and low income pregnant women may qualify for Medicaid.  The Medicaid expansion opens up eligibility to more by allowing for low-income adults (with or without children) to qualify for the coverage.  Because the Supreme Court ruled that it must be state choice to expand Medicaid individuals of similar economic circumstances in two different states are under different eligibility guidelines. For example, "Tom" in New Mexico can qualify for Medicaid and have access to doctors and hospitals despite his low income, while "Sam" in Georgia does not have that same access, although both do not have children and unable to afford healthcare without financial assistance.

While some conservative/Republican dominated states in terms of party loyalty or leadership have changed their minds and accepted the expansion, most have not.  As can be seen in the interactive maps provided by The New York Times at "We Mapped the Uninsured", the states that have declined the expansion are typically conservative in their politics, with Republicans usually dominating voting for key political offices, such as Governor or the state legislature. 

The Reverse Income Effect

There is another dynamic to the Medicaid expansion issue that is of interest.  This is the phenomenon studied in Political Science known as the "reverse income effect".  Notice that the dichotomous display of color in the expanded/not expanded Medicaid map above is very similar to the pattern in the Presidential election results maps for 2008 and 2012.

In most cases the states on the Medicaid map that did NOT expand Medicaid, are the "red" states on the presidential election maps that depict which candidate, Republican or Democrat, that the state's electoral votes were awarded to.  This, of course, is typically determined by the winning candidate of the popular vote count in that state.  The New York Times maps show that the states with the highest number of uninsured are these very red states.  Also important, is that these states had the highest number of uninsured to begin with, and still do since the states have chosen not to expand Medicaid under the ACA.  Perhaps more red states in the near future will opt in to the expansion under the increasing pressure of the uninsured.

This similarity brings up the political science phenomenon of the "reverse income effect".  If we look at data depicting voting patterns among low income and then among high income individuals we see that high income individuals are more likely to vote Republican, while low-income individuals are more likely to vote Democrat.  This is usually explained by the fact that Republicans are conservative in ideology, preferring lower taxes on businesses and individuals, even on high income earners, as well as less regulation on businesses.  Higher income make up a higher percentage of business owners.  Democrats tend to be more supportive of programs and regulations designed to benefit or protect consumers and low-income individuals.  This, perhaps explains the increase in support for Democrats as income decreases.  In the 2012 Presidential Election, roughly 60% of voters earning less than $50,000 annually voted for President Obama, the Democratic candidate.  This is true for previous and recent presidential elections.   The percentage may have been higher had more low-income individuals voted in the election.  Voter turnout rates tend to be lower among lower income level groups.

The "reverse income effect" notes that while lower income individuals tend to vote Democratic, and higher income individuals Republican, the same is not true if we look at statewide data against electoral vote outcomes.  As the map to the left suggests when analyzed next to Presidential election outcome maps, the states with the lowest median income levels, the poorer states, tend to award Republican candidates more votes than Democrats for  the Presidency and various state-wide offices; while the states with median income levels in the higher ranges tend to award Democrats their electoral votes and votes for various state offices.  In the map above, the darker the blue shading, the higher the median income level of the state.  The light blue states have the lowest median income levels.  Notice that most, if not all, of the states depicting the two shades of light blue are the states that are considered to be conservative in ideological leaning and Republican  party dominated.  Therefore the lower the income level of the individual, the higher the probability of voting Democrat; but the lower the median income of the state, the higher the probability of the state giving electoral votes to the Republican.  This paradox is interesting but may be explained by the presence of other variables that influence voting.  For example, Republican dominated states are usually more socially and culturally conservative in terms of voter makeup, which may explain why these states, despite having lower incomes on average, tend to allow for Republican victories.  Additionally, minorities (especially blacks and Latinos) tend to vote Democratic for economic and political reasons, such as support for civil rights protections.  Blacks and Latinos make us a disproportionately large share of low-income earners and those living below the poverty level, which is one explanation for why votes among low-income earners tend to go to Democrats, but why statewide data suggests the opposite, higher probability of voting Republican.  

Back to the Medicaid Expansion 

Now looking at the Median income level map in comparison to the "Expand/Don't Expand Medicaid" map, it is apparent that the states that may be most in need of expanding Medicaid coverage in terms of median income levels and inability to afford healthcare without assistance, are the very states that rejected the federally funded expansion of Medicaid under the Affordable Care Act.  Therefore, the states that will not expand Medicaid have a disproportionately higher share of individuals who will not qualify for Medicaid under the current requirements but cannot afford health insurance, or even health care for that matter without assistance, assistance which their state has rejected.  

Impact of Rejecting the Medicaid Expansion on Hospital Access in Rural Communities

Citizens in rural areas, which are largely found in lower median income and conservative states will also begin losing access to hospitals and emergency services if the state continues to reject expansion of Medicaid. In the crafting of the ACA, rural hospitals agreed to lower their Medicare reimbursements in exchange for getting more patients with health insurance under the act.  Rural hospitals a high percentage of health services that are provided to those with low-incomes who cannot then pay for those services.  Therefore, having insurance coverage for low-income, such as Medicaid, means that these hospitals will receive payment for the services that they are under obligation to provide when provided to someone that is low-income or poor. However, these rural hospitals are closing one by one in states that rejected the Medicaid expansion.  Rural hospitals are facing closure because they have been hit twice, in that they lowered their Medicare costs but are not receiving payment for services in return from individuals who would be able to pay for their healthcare, but for their state's decision to deny that individual Medicaid coverage.  The closing of rural hospitals means that many individuals in this nation will be, in many cases, as much as 40 miles from the nearest hospital and emergency room.  This could mean the different between life and death, or healthy or disabled for many in rural communities.  Again, the states most impacted by this, those composed largely of rural areas, tend to be the conservative/Republican dominated states that rejected the Medicaid expansion, and will, as a result, likely see hospital closures in those areas.  In Georgia, as of November 2014, five rural hospitals have closed and another six likely to close in the future. Since 2010, 43 rural hospitals have closed nationwide.  It is likely that this gap between Medicaid-Expanded/ higher-median-income states and Medicaid-not-expanded/low-median-income states will narrow as states that rejected the expansion will be pressured to reverse course.  This will only happen as the Affordable Care Act becomes less partisan and more time has passed since the act itself was passed.  (Source: http://www.usatoday.com/story/news/nation/2014/11/12/rural-hospital-closings-federal-reimbursement-medicaid-aca/18532471/)

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The Problems With the Differing Perceptions on Race Relations and How These Misunderstandings Get Us Nowhere

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The Fact of Biases

Many whites, by no means all, do not understand the Ferguson protest, largely because they do not see the larger context from which the protest has emerged.  Comments opposed to the protest are too focused on rioters behaving badly and completely neglect the decades old concerns of those that are against violence and engaged in peaceful protest for differences in treatment of some under the law .  Many whites are resistant to claims that race plays a role in the treatment of individuals by others, by society in general, or by government.  I think the scientific argument concerning life on another planet, serves as a great metaphor here.  While we may not be able to prove that life exists elsewhere outside of our solar system, it would be illogical to assume that in the vast expanse of space, that there is no other life.  Therefore, it is not a matter of "if", but "when".  Is it also illogical to assume that race rarely plays a role given our history?  Our Constitution, effective beginning 1789, is about 225 years old.  For one-third of that time, we enslaved people of color under the assumption that they had, nor deserved basic rights to life and liberty.  Although slavery ended in 1865, many states, both southern and northern, continued to deny basic rights to life and liberty, as well as political rights to blacks.  These denials came in the form of lynchings, all white juries, segregation, and requirements designed to make it nearly impossible for a black person to register to vote.  These policies only ended in the 1960s.  Therefore, for 75% of our history, an entire group of people who share a common skin color, have been denied basic freedoms and protections that many of us take for granted.  Moreover, it is often neglected that it was not the Southern racial majority that led the charge for change. Quite the opposite.  The South resisted.  Civil rights protections and an end to discriminatory policies such as segregated school and public accommodations were forced on the South by the courts, by protesters and by federal legislation enforcing compliance in the face of noncompliance.  Therefore, it is safe to argue that white perceptions of blacks inferiority did not disappear by 1970, 45 years ago.  Therefore, current generations alive today, that were also alive then, may continue to hold these perceptions; and may have passed them on to some extent to their children.  Racism is typically something that is taught.

White perceptions of inferiority of blacks, a perceptions that was fueled decades ago in order to support the enslavement and denial of other rights of blacks has now morphed into assumptions as to why such a large percentage of blacks live in poverty and why crime rates are much higher.

White feelings of black inferiority now are typically only seen in our "implicit biases", rather than manifested in more explicit ways as before.  In the decades following slavery, whites took on feelings of fear and intimidation.  Don't believe me?  If you are white, tune in to your gut reaction when you drive through a black community.  You say, "it is not because they are black, it is because the poor community also has a high crime rate".  That me be true, but the reaction continues to happen outside of black communities when coming across a young black man.   Many whites hold more sinister assumptions about a black man walking down the street, than they do about a white man.  Additionally, the same reaction does not tend to happen in poor white communities.  Many whites are more fearful of entering an impoverished black community, than they are of entering an impoverished white community, such as a run-down trailer park.  White feelings of fear and intimidation impact our responses to situations involving a black person.  We can debate the source of those feelings, but they exist nevertheless.  My comments are not an attempt to bash whites, only an attempt for us to be honest with ourselves so that we can progress further in our race relations.  Differences matter, whether we want them to or not.  We make assumptions of a group of a different color.  This goes for blacks towards white as well.  I had a black student inform me once that his mother, given the history of white treatment of blacks in this country, had a strong dislike for white people in general.  However, our assumptions due to differences are not isolated to differences in skin color (black, brown, white, etc.).  We make assumptions about people from other countries, and about the other gender.  It is human nature to try to determine facts based on the information we have first, which is how someone looks most of the time. 

There is a great deal of research, surveys, and other forms of data that support different outcomes overall between blacks and whites.  If you do not believe the data, or you do not want to see the significance and meaning of the data, you must stop reading here.  If you never believe the data, no matter the topic,  you are always right in your opinions, and as a consequence, can never be proven wrong.  For all others, the links below provide a small window into the world of data on race relations and civil rights.

Implicit Bias:

http://www.cnn.com/2014/12/03/opinion/kohn-ferguson-implict-bias/index.html?hpt=op_t1

Recent research has found that differing treatment as a result of perceptions and subconscious biases begins as early as grade school:

http://www.indiana.edu/~equity/docs/Skiba%20et%20al%2054%204.pdf

http://www.mintpressnews.com/black-and-hispanic-students-punished-more-severely-than-white-counterparts/191496/

Race Relations, Perceptions and Claims About Race in the Context of the Brown and Eric Garner Deaths

Back to the issue of the police.  Do Americans want a bigger police presence in areas of high crime?  Yes.  That is a shared feeling among whites and blacks. I would also argue that law abiding citizens living in impoverished areas where crime is high, being the group most victimized by that crime, would also want to see a greater police presence.  Surveys show that blacks, being most likely to be a victim of homicide, are much more likely to favor greater gun control.  What minorities in impoverished and crime ridden communities do not want is different treatment solely because of color or a stereotype.  In other words, stop and frisk itself is not unwanted in these areas.  Rather there is a desire to see that harassment is not common place when there is no evidence of a crime.  Or find that in place of "reasonable suspicion", there is only a preconceived idea that this person must be a criminal because they are black and wearing a hooded jacket, or that they must be an undocumented immigrant because they are Latino.  This would be similar to stereotyping individuals with tattoos as uneducated, unsophisticated and "up to no good".  Only, in addition to tattoos, having a dark skin color is a signal of potential wrongdoing and "thuggery".

Nevertheless, implied bias and stereotypes are not excuses to neglect fact and to run to the opposite corner, seeing nothing other than discrimination and racism.  This is unfair is the same way that it is unfair to attack anyone and anytime a claim is made that there is a racial component in an event or issue.  When the data says 60% face a certain kind of treatment, one side converts that to 100% and the other side converts that number to 0% in their underlying assumptions.  Both mistakenly, as a result, are going to neglect data, additional variables, facts, and context in their limited analysis of the issue or event. 

Calls for Action and Policy Prescriptions Based in Strategic Thinking, Reality and Objectivity

There are broader concerns, both racial and non racial, that are brought up by the recent deaths of unarmed citizens in incidents involving law enforcement .  Additionally, there are many concerns with policy that are not racially driven policies, but if addressed, would reduce a lot of the disproportionate mistreatment handed to black citizens.  For example: 1.  Better training of officers in perceiving threats 2. Body cameras.  3. Rethinking stand your ground laws so citizens do not see them as permission to take the law and public safety into their own hands when a threat does not exist or as a reason to shoot down anyone that steps on their property under any circumstances.  Perhaps murder convictions, like that of the white man who shot a young black women in the face through his front door when she was seeking help after a car accident, will help with this latter point.  So called "Stand Your Ground" laws of some states appear, according to coverage, to be particularly problematic for blacks.  To be objective, there is not much data on this, likely due to the newness of these laws.  

In thinking about incidents of deaths at the hands of law enforcement, we must take an objective and sensible approach.  Cops cannot always be held to the same standard as an individual.  If a cop does willfully kill someone out of malice, or extreme abuse, then yes, they must be punished the same as others.  However, we do not immediately throw murder convictions on cops every time they fire their gun and suspect dies, even when the suspect is unarmed.  When a suspect is running, perhaps towards law enforcement, whether they are armed or not, but they do not stop as instructed, don't we understand the need for law enforcement to shoot?  Police must make split second decisions in situations where they have a great deal of uncertainty.  Furthermore, don't we all understand that law enforcement rules of engagement must be different than that of an average citizen given the job and responsibility of the police?

I caution those that immediately jump to Michael Brown's defense, in the same way that I cautioned others not to re-actively take the side of George Zimmerman in the Trayvon Martin case.  Those defending Brown at all cost and no matter the circumstances need to understand that the facts of Brown's case are detracting from the cause.  The Michael Brown case is not the best case to present the argument of disproportionate and discriminatory treatment of blacks by the police.  However, Brown is not Trayvon Martin and, and for that reason, it is unfair and lacking in objectivity to all on both sides to portray these cases as the same.  But it is hard to contain a ground swell of public opinion and community action once it has started; neither is it a good idea to waste the opportunity presented by the overwhelming reaction of the public to the Brown, and then to the Eric Garner case, among others.  It is very important that the political and community leaders educate the public on their perception, their concerns and their goals, being sure to separate this from the Brown case.  Bring up the Trayvon martin case, but educate followers in the complexities of the Brown case, openly acknowledging the possibility that Brown was a legitimate threat. Community leaders can do this while still point to a problem that should be addressed.   When using the hands up gesture be clear that it is representative of a larger problem, and be clear that there is an understanding that Brown may not, mostly likely did not, have his hands up.  He was unarmed but nonetheless he felt big and strong and unstoppable, something that he portrayed in the convenience store video of the robbery where he felt no need to have a gun in assaulting someone and taking what he wanted.  Brown felt empowered.  In summation, this movement cannot be all hear; it must be strategic and political as well.  Only that way will there be success in the long-run.

Political and community leaders cannot be angry at small gains, nor allow anger of their followers to go unnoticed.  They must educate the community about the legislative and democratic process.  Seemingly small gains, such as body cameras or others listed above, are indeed significant and meaningful gains. Democracy, especially within a federal structure such as ours with multiple governments enacting policy, is a big ship that moves slowly and cautiously.  Leaders and followers of both sides do all an injustice by perpetuating a narrative that is unrealistic and unfair.  Let's have a discussion because we need one, but let it be an honest and productive discussion.

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Martin and Brown: Cases Highlighting Vastly Different Perceptions and an Effort to Understand Them

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Differing Perceptions On Display

One only needs to scroll through social media feeds, watch clips from various talking heads on cable news networks, or tune into radio news talk shows to see that there is a striking difference between most white perceptions of the Brown incident and most black perceptions of the incident.  The problem is that the perceptions on both sides neglect fundamental facts and concerns.  Rather, both sides take an "all or nothing" approach, jumping into their usual defensive postures.   Either the comment is made with the implication that Brown was not doing anything wrong and that the officer is a murderer who should have been immediately arrested; or the comment implies that racism and discrimination do not exist, and that to say so is simply "race baiting". The "race baiting" charge is then followed by a comment that is racist itself and proves the underlying biases of the comment maker.

Those in support of Michael Brown equate his circumstance with that of Trayvon Martin's, intentionally or not portrays Brown as a law-abiding and non threatening teenager.  Those against the Ferguson protests also equate Brown with Martin, but with the implication that both were criminal.  Both narratives exist despite the fact that Brown had just assaulted a convenience store owner, feeling empowered even without a gun; and, despite the fact that Martin had done nothing criminal to warrant the following and harassment by George Zimmerman, who is now assumed by some as a member of law enforcement.  In one narrative they are both innocent victims and in the other equally incorrect narrative they are both criminals.  There are fundamentally different facts between these two cases that a frighteningly large percentage of Americans seem to overlook or be unaware of.   I want to simultaneously cry in sadness and pull my hair out in madness. 

Comparisons attempting to depict Wilson and Zimmerman as victims; Brown and Martin as "thugs".

Image equating the circumstance of Michael Brown with that of Trayvon Martin

My favorite, and I say this sarcastically, are the comments of those that claim to not understand why Trayvon Martin's shooting received so much media attention, while a random white guy or white girl's murder by a black man did not warrant the same attention.  Often times, I find the poster to the right is shared to prove this claim that there is a possible reverse racism or effort to "race bait".  The question in the poster: "What is the difference"?  The maker of the poster and those that share the poster fail to recognize the difference.  The difference is that in once case there was no question as to whether or not the shooter should be captured, put on trial and punished. In Martin's shooting, it appears to have taken public pressure by the black community to arrest and put on trial the shooter of Trayvon Martin.  Whether you believe the narrative or not, this is why the black community and others were outraged.  To water down the these cases to a similarity of death v. death at the hands of someone of the opposite race missed the point. This oversimplification seems to occur within both perceptions. 

Survey Data as Evidence

The differing perceptions of whites and blacks regarding race, discrimination, and treatment in the criminal justice system have been present before these two incidents.   Survey after survey supports what I anecdotally witness on the internet and television, and even among my students.  The Pew Research Center survey (right) and the first two Gallup surveys (below) illustrate that whites are more likely than blacks to believe that racial equality has been achieved and that claims of racism or bias are usually exaggerated or unjustified.  The Gallup survey results below dig into differing perceptions among blacks and whites regarding police.  

 

 

Contemplating the Origin of These Perceptions

Seeing this, it isn't hard to believe why the black community is skeptical about the account of the shooting given by Officer Wilson and the Ferguson police department.  If you look at the treatment historically of unarmed, innocent and peaceful black citizens, especially leading up to and during the civil rights movement, the distrust of law enforcement is even more understandable.  This is a history that includes the use of dogs and painful fire hoses on peaceful protesters, racial profiling in car stops, and the coordination of top law enforcement officials with lynch mobs and the KKK.  However, perceptions of whites may often neglect experiences of whites in the same way that perceptions of whites by blacks may be neglecting the experiences of blacks.

The high rates of crime in minority communities, the fact that blacks make up a disproportionate share of those in prison, and the frequent coverage of the media of crimes committed by black suspects fuel white fear and intimidation.  Whether the coverage is objective and proportionate or not is a separate matter.  The point is the views of some whites should not be lost on those that claim whites hate blacks for simply being black, claiming a racism that continues from decades of unequal treatment.  Does pure racism motivate the opinions of some?  Most likely, but this should not be the characterization of the whole group, in this case a characterization of all whites.  At the same time, it should not be assumed that all blacks hate whites as a result of historical treatment of blacks by whites.  However, the feelings of whites should not be lost on whites that claim there is no assumption made by them of wrong-doing by blacks, but then point to the high crime rate among blacks as support for the feeling they just denied as impacting their views.  While we attempt to explain our own biases, we should also confront those biases and recognize when they may be leading to an unfair and somewhat false perception of a situation, person, or group.

Confronting Perception and Bias

As a society, we cannot run from these perceptions, and we cannot deny they differ nor deny that the differing perceptions may be justified. As individuals we do ourselves an injustice, myself included, if we consistently take on a defensive and antagonistic stance.  Since we are all guilty of this, the solution is easier stated than done.  However it is not impossible for a society to confront its demons and have uncomfortable conversations.  All types of biases exist that inform our perceptions, whether they are racially motivated biases or motivated by someone's economic condition, beliefs, or weight.  We cannot deny our own biases but then argue for the bias of another.  What must equally be avoided is the act of dismissing racial biases because they are uncomfortable to talk about with a willingness to discuss less controversial biases.  Thankfully, we have seen confronting uncomfortable histories and biases successfully done in other countries without an unraveling of social order.  Both perceptions exist for a reason.  These are perceptions that have been fueled partly by reality and partly by biases that have been passed down from one generation to the next.

In a coming article I will explore in greater detail the problems with these perceptions and make specific suggestions regarding the Ferguson, Missouri protest. 

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