Ideology Over the ACA Keeps Some Health Insurance Coverage Gaps Open

31 October 2013
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By Samantha Kumar and Terri Jackson

The ideological rift over the Affordable Care Act (ACA) brought the U.S. federal government to a standstill for more than two weeks. Despite the stalemate, the 16 days also brought memorable moments including a Jimmy Kimmel segment interviewing Americans that thought that the ACA and Obamacare were different pieces of legislation, a 21-hour filibuster involving a Dr. Seuss inspired poem and a Miley Cyrus parody that most of us would like to forget.

But the fundamental question of whether Americans believe that access to health care is a right or a privilege remains unanswered.

Support for social insurance schemes fluctuated over the past few decades but ultimately they have become invaluable safety nets. Medicare, a single-payer insurance program for the elderly, was passed in 1965 amidst staunch conservative opposition but is now the “third rail” of politics. However, the synergy of ideology and public perception appears to be on a different course for the ACA partly due to the response to Medicaid expansion.

Despite evidence for the benefits of Medicaid expansion and the influx of billions of dollars of federal funding for health care in states that opt in, nearly two-thirds of low-income individuals initially intended to receive coverage from the Medicaid expansion live in the states that have opted out or are still undecided. This resistance to Medicaid expansion could widen existing health disparities. Residents in states that are opting out are sicker than in those that are opting in. For example, rates of colon cancer deaths in anti-expansion states are an average of 16% higher than in pro-expansion states.

In a poll conducted earlier this year in southern states opting out of Medicaid expansion, 62% of residents support the expansion. However, Arkansas is one of the only states in the south to opt in to Medicaid expansion using an alternative that will allow them to provide a “private option” to eligible beneficiaries. Its neighbor, Mississippi, has the largest percentage of poor and uninsured individuals in the country and has opted out of the Medicaid expansion thereby rejecting an estimated $426 million in federal funds for next year. Residents in Arkansas living 133% under the federal poverty line will be eligible for Medicaid but on the other side of the state border you have to “be almost dead before you can get Medicaid in Mississippi,”  a resident of that state explained.

It is difficult to reconcile vehement political opposition to Obamacare as “socialized medicine” in contrast to emphatic support of nearly universal coverage for the elderly under Medicare. Attitudes toward class divisions contribute to the problem: the structural isolation of the poor under Medicaid often enforces the belief that Medicaid beneficiaries do not deserve government hand-outs. After a history of separating the deserving and the undeserving, the ACA could shift these attitudes and level the playing field for Americans seeking health insurance coverage. The roll out of Medicare was an opportunity for the civil rights movement to integrate hospitals in the south. Will the legacy of the Affordable Care Act be the integration of the uninsured into the health care system?

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