Unhealthy Citizens, Unhealthy Democracy

 By Josh Carpenter*

The United States has two distinct health systems for the poor: generally, one for blue states and one for red states. One system provides health insurance to the disadvantaged through Medicaid expansion. Over 30 states have elected to expand Medicaid through the Affordable Care Act or opted for a modified version. Democrats in statehouses across the country have led this push, although Kentucky and Ohio are important exceptions.  Unfortunately, individuals in 19 states are being denied access to healthcare.

Consequently, the same person could be eligible for insurance in Arkansas, but over the border in Texas, she is uninsured and living in the “Coverage Gap.” This Coverage Gap largely falls along party lines. How did we get here and why does it matter?

In National Federation of Independent Business v. Sebelius (2012) the Supreme Court decided that states should not be mandated to expand their Medicaid eligibility thresholds as outlined by the Affordable Care Act (ACA). The Supreme Court’s decision to decouple Medicaid expansion—which guaranteed healthcare to individuals living below 135% of the Federal Poverty Line—from the remainder of the healthcare law devolved the decision to expand Medicaid to the states, leaving healthcare access for millions of Americans to the discretion of Governors and state legislatures. Many states decided not to expand Medicaid, most of them led by Republicans in the South. Consequently, the law became even more complicated and its impact, unevenly distributed.

When we deny health insurance to the poor, we create several troubling outcomes. Poor people suffer tremendous health disparities. In the Deep South, these disparities are particularly acute along racial and ethnic lines. African Americans, for example, experience disproportionately worse health outcomes than other races.

People without health insurance face significant barriers to accessing care, a problem exacerbated in rural areas with fewer treatment facilities. For example, one in four expectant mothers in rural Alabama receive inadequate prenatal care, contributing to Alabama’s high infant mortality rate. In fact, the average infant mortality rates in Alabama, Mississippi, and Louisiana are so high that they rival that of Botswana.

Denying health insurance to the poor also diminishes a sense of citizenship among the uninsured, stifling their willingness to engage in political participation. My doctoral research investigates the voting behavior of 332,000 Alabamians living in the Coverage Gap. I discovered that less than one-third of these citizens were registered to vote, symptomatic of the difficulties poor people face in registering to vote in Alabama. After conducting a randomized Get-Out-The-Vote field experiment, our intervention found that political mobilization among this population to be a tough sell.

The uninsured Alabamians I interviewed were neither ignorant nor apathetic. They were disconnected. The parameters of extant public policy were drawn to exclude them from receiving public benefits. Indeed, although they conceived of themselves as “outsiders” in electoral politics, they were committed spectators to the policies that those politics generated. Their state—my state—had legislated their social exclusion.

Policy designs have profound effects on subsequent democratic participation, particularly among the poor who live with limited healthcare access. The consistent disengagement of poor, uninsured citizens likely contributes to America’s low voter turnout.

We can and should do better to improve the health of America’s people as well as its democracy.


* Josh Carpenter is a DPhil candidate in Politics at Oxford University where he studies on a Rhodes Scholarship. He was the Co-founder and President of Bama Covered, a student-led, grassroots non-profit that informed Alabamians about the Affordable Care Act in 2014.


Image by Tomasz Sienicki [user: tsca, mail: tomasz.sienicki at gmail.com] – Own work, Public Domain, https://commons.wikimedia.org/w/index.php?curid=121371

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