New research published in the Journal of Health Politics, Policy and Law revealed that public support for Medicaid expansion is related to state adoption, but this public support is racialized. Using complex statistical wrangling, the authors answered five questions: (1) Does public support for Medicaid expansion vary across states? (2) Is public support related to state adoption? (3) Is support racialized? (4) If racialized, is white support more important than nonwhite support? and (5) Does the size of the nonwhite population matter more when white support is relatively low?
Public support for the Medicaid expansion did vary across states – the average across all states was 51% in favor of the expansion, with a range of 45 to 55% across most states. As overall public support for Medicaid expansion increased, the likelihood of state adoption also increased by about 45%. However, state partisanship was by far the most robust predictor of state expansion; states with Democratic governors demonstrated over a 10-fold likelihood of expanding Medicaid. Support for Medicaid expansion was indeed racialized, with about 45% of whites supporting expansion, as compared to almost 73% of nonwhites.
There was more evidence of state responsiveness to white support; as white support increased the likelihood of state adoption increased almost twofold, but as non-white support increased there was no significant effect on states expansion decisions. Furthermore, as the proportion of Blacks in the state increased, white support decreased, and the state was less likely to expand Medicaid. The authors attribute this to increased racial resentment among whites who live in areas of the US with a greater proportion of Blacks.
The authors conclude that the Supreme Court decision to allow states a choice in Medicaid expansion was based on the assumption that states would act in democratically accountable ways. However, this study brings that into question.
It is interesting to consider patterns of voter suppression, which disproportionately affect Blacks in the southern US – where many of the 19 states that have not adopted Medicaid are clustered. It may be that Blacks, who overwhelmingly support Medicaid expansion, have lost their voice in these states.
commentary by Megan Doede
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.