Republicans in seven of the ten states in the country with the highest percentage of African-Americans have declared they won’t participate in the Medicaid expansion in the Affordable Care Act, potentially denying tens of thousands of blacks health insurance.
As originally written, “Obamacare” required states to expand Medicaid next year to nearly all residents whose income is below $16,000 ($32,000 for a family of four), with the federal government footing almost all of the bill. But the Supreme Court ruled last year that states could choose not to participate in the expansion, resulting in a predictable partisan divide in which states run by Republicans have generally opposed the new Medicaid funding while those controlled by Democrats support it.
Nearly every state in the conservative South is opposing the Medicaid expansion, as the Associated Press reported earlier this week, and many of those places have sizable black populations, such as Mississippi, where about 37 percent of people are African-American, the highest percentage of any state in the country. And while there is little data breaking down potential Medicaid recipients in each state by race, it’s clear large numbers of African-Americans could lose out on health insurance if their governors don’t change their minds. In Mississippi alone, more than 200,000 people of all races would gain insurance under the law, and African-Americans are disproportionately low-income, so it’s likely they would consist of more than 37 percent of the people newly eligible for Medicaid.
Opposition on ideological grounds
Many Republican governors oppose the Medicaid expansion on ideological grounds, having long been wary of government-run health insurance programs. Others argue that while the federal government is now funding 100 percent of the Medicaid expansion, meaning the states literally pay nothing to have more of their residents insured, that level of support will eventually fall off, leaving states with the choice of either taking away insurance from people who just received it or going into debt.
“Texas will not be held hostage by the Obama administration,” said Texas Gov. Rick Perry in a recent press conference. He said his state’s budget would “crumble” under the Medicaid expansion.
Obama administration officials strongly dismiss the GOP governors’ complaints about costs. They have emphasized to states that the federal government intends to keep paying for the new Medicaid recipients and note that states can always withdraw from the new Medicaid funding if they want.
But while some liberal activists have sharply criticized the Republican governors, the Obama administration is for now taking a more measured approach. They are looking for innovative ways to encourage more GOP governors to participate in the Medicaid program, which would offer insurance to more than 15 million Americans if implemented by all states.
Some Republican governors and state legislatures, in consultation with the administration, are considering using the Medicaid funding to purchase private insurance for their low-income residents, thereby not increasing their Medicaid programs directly but expanding coverage to low-income people. A few of the states considering this idea, such as Louisiana, have large minority populations, although some states, including Texas, have already ruled it out.
Sebelius strikes back
Kathleen Sebelius, head of the Department of Health and Human Services, has repeatedly said that even though several Republican governors have proudly announced they will not accept the Medicaid money, these governors will cave eventually, under pressure from doctors and hospitals in their states who are wondering why they won’t accept billions of dollars from the federal government.
“It not only would bring more people into the health care system, but it would dramatically reduce unpaid medical costs,” Sebelius told USA Today in a recent interview.
But her confidence may ignore the intensity of conservative opposition to the overall health care. Declining the Medicaid expansion has become one of the last ways for conservatives to express their discontent with Obamacare and position themselves for a potential presidential run or avoid a Republican primary for reelection as governor. Of the Republican governors who have said they will participate in the Medicaid program, all but two are in blue states that Obama won in 2012. And even getting the governor’s support is often not enough: after Florida Gov. Rick Scott, a Republican, suggested he would accept the Medicaid money, Republican state legislators have said they will try to block such an action.
This ironclad GOP opposition particularly affects African-Americans. Millions of blacks live in places like New York (which has the highest number of blacks of any state) that are embracing the health care law. But the center of the Republican Party, and therefore opposition to Obamacare, is the South. And there, a band of states with large black populations is opposing the law: Alabama, Georgia, Louisiana, Mississippi, North Carolina, South Carolina and Tennessee and Texas.
Follow Perry Bacon Jr. on Twitter at @perrybaconjr