The Affordable Care Act (ACA), more commonly referred to as “Obamacare,” was passed into law in 2009, with most major components put into effect by 2014.

It was designed to close racial disparities in access to health care – it’s there in the language of the bill, said Jamila Michener, assistant professor of government in the College of Arts and Sciences. The original text, she points out in new research, contained dozens of references to “disparities,” “discrimination” or “non-discrimination.” The bill also mentioned “racial” or “race” 33 times and “ethnicity” or “ethnic” 35.

Although the ACA succeeded in reducing racial and ethnic disparities in health insurance coverage and access to care in its first decade of implementation, many of the provisions aimed at racial equity in the ACA have been obstructed by racial politics, Michener wrote in a paper published in the Journal of Health Politics, Policy and Law.

Credit: Official White House Photo by Pete Souza

In her article “Race, Politics, and the Affordable Care Act,” Michener examined ways that racialized political processes block equitable material outcomes, making ACA a test case for race and politics in the United States.

“The ACA underscores a critical tension between politics and policy in a racialized polity,” she wrote in the paper, defining “racialized” as “economic, social, and political processes by which people are sorted into racial categories, resources are distributed along racial lines, and state policy shapes and is shaped by the racial contours of society.”

“Even when policies are intended to winnow racial disparities, politics can undermine the steps necessary to do so,” she wrote. “Close attention to the implementation of the ACA reveals how race intersects with politics to render public policy less equitable.”

Michener, who studies health policy as well as racial inequality, hopes that by scrutinizing the ACA and other intersections of policy and politics, she will work toward racial justice.

“The ACA is one of the most far-reaching policies ever passed, and it aims to affect an arena (health) that is most acutely relevant to people of color,” she said. “Racial health disparities are cutting lives short, hurting communities and hindering our democracy. The ACA explicitly aimed to change that, so it is both natural and necessary to evaluate the ACA on those exact terms, with respect to race.”

Michener outlined two specific ways that racialized politics have blocked equity-making provisions in the ACA: through setbacks to efforts to expand Medicaid; and through barriers to implementation of general provisions in the bill that were intended to close racial disparities.

The ACA proposed to reduce racial inequality by expanding Medicaid to offer public health insurance to all Americans with incomes at or below 138% of the federal poverty line. The act offered states, which administer Medicaid and share the costs, a variety of financial incentives for joining and penalties for opting out.

The goal: making Medicaid coverage more even across the country. That would have inequality-reducing racial effects, Michener said, because of the outsized presence of blacks and Latinos living in or near poverty; 20% of Medicaid beneficiaries are black and 30% are Latino.

Political processes, however, interfered with the plan to expand Medicaid coverage. The 2012 Supreme Court decision National Federation of Independent Business v. Sebelius ruled that threatening noncompliant states with the loss of all Medicaid funds was coercive. This decision opened the door for states to eschew Medicaid expansion free of penalty, Michener  said, and many did – largely along party lines.

Some of the states that refused to expand Medicaid, she said, were Southern states with substantial populations of color.

“States with Democratic legislative majorities and Democratic executives adopted the expansion most swiftly,” said Michener, “while states with divided governments or Republican legislative majorities were less likely to do so, particularly in the South.”

In addition to Medicaid expansion, other provisions in the ACA aimed at diminishing racial disparities have been limited because of political conditions, Michener found. These provisions include:

• consistent and systematized health data collection by race, ethnicity and language;
• increased health care workforce diversity; and
• nondiscrimination in health programs and activities.

All three policy goals could increase health equity, but all have encountered political obstacles, Michener said. She also found evidence of very low enforcement, under the Trump administration, of the systematized health data collection required by the ACA.

And although the ACA contains numerous provisions to enhance racial diversity, Congress has blocked appropriations to implement these provisions, even in the Obama era.

“The shift in federal priorities since the election of President Trump has further imperiled funding,” Michener said. The fiscal year 2020 budget proposal for the Department of Health and Human Services, Michener said, has proposed eliminating $88 million for diversity training and $151 million for nursing workforce development.

As the 10th anniversary of implementation of the Affordable Care Act approaches, such obstacles to implementation say much about race in America, said Michener: “Conversations about health care and racial equity are as crucial as ever.”

Kate Blackwood is a writer for the College of Arts and Sciences.