The Grip of Stratification on Health Insurance

Earlier this week the New York Times released an article with data from Enroll America in conjunction with Civis Analytics discussing the localization of uninsured adults in the United States. Though this may not be entirely reputable, the 2014 census data released in September of 2015 was also present and displays a similar localization, with the 2015 estimate only furthering the concentration. The studies found that the Affordable Care Act (ACA) did in fact reduce the number uninsured adults in America significantly. However, the places where the numbers of uninsured remained steady was predominantly in poor neighborhoods in the South, with the front runner states being Texas, Mississippi, Louisiana, Georgia, and Florida, with Oklahoma and Montana as honorable mentions. While before 2013, when the ACA began, the percent of uninsured Americas was over 15% in most states, this dropped to around 12% in many places. What the article added though was that states with the least amount of change in uninsured rates were states that chose not to expand the qualifications for Medicaid, a government social program which allows low income families to receive what is effectively health insurance if they are at or below the poverty line. While the ACA would normally extend the requirements for Medicaid to slightly above the poverty line, (138% FPL) which coincides with the income bracket at which a person can start receiving tax credits for having insurance.  However states can opt out of this expanding of Medicaid qualifications which leaves what is referred to as a “Medicaid gap” where people who are just above the poverty line are excluded from any government assistance since thy make too much to qualify for Medicaid but do not make enough to qualify for government subsidies.

            This reads like a page out of Douglas Massey’s book. It is an institutionalized mechanism of class-based stratification. The system is designed to punish the poor and will take this group of people, roughly three million adults, and put them at high risk of becoming impoverished. For those in this income category of $15,930-21,187  for a household of two have no insurance, there is no safety net if they are hospitalized which can cost on average anywhere from $5000 to $13,000. Suddenly incurring debt that is equivalent to anywhere from a quarter to almost 80% of their yearly income would be devastating financially, and then feeds into the other mechanisms of stratification such as incurring privatized debt and added legal difficulties in escaping this debt.

            The ACA is akin to many of the social programs that FDR and LBJ implemented to challenge this class based stratification. Like all social programs, it shifts the cost onto the government and in order to sustain this that cost will need to be paid for by the upper class in the form of higher taxes. Though Obama was attempting to shift the political economy of the US back towards benefiting of the middle and working class, it seems that the current political economy is simply too entrenched at the moment to allow such strong legislation. The original ACA would impose the expansion of Medicaid onto all of the states, but this was blocked by the Supreme Court which created the opt-out mechanism. Consequentially the ACA lost a lot of its power to assist those in the lower class.

America is exceptionally divided politically at the moment, and as Massey cited, this usually ends with the government/legislature benefiting the upper class financially. When things like the ACA lose strength, the reason for this benefit becomes apparent. The cost of healthcare is put onto the poor themselves, which they cannot afford, and then must appeal to those with money for assistance, at a cost which benefits the wealthy. Meanwhile the government is not raising taxes on the wealthy to pay for the government programs, so the cost is not put upon them and they continue to lose no income or wealth from the system. 

Though this all seems point to a system that entirely benefits the upper class and reinforce stratification, this is in the context of the small sticking points in an overall large shift in the political economy. The passing of the ACA was a massive step in shifting the scales in the favor of the middle and lower classes and undoing some of the mechanisms of stratification. It was still able to reduce the number of uninsured adults by a significant margin. If the ACA is able to stay active for the long haul, and other legislature like it is passed, we could potentially see degradation of the stratified system in the coming decades.

Bibliography

“2015 Poverty Guidelines.” 2015. ASPE. Accessed November 2. http://aspe.hhs.gov/2015-poverty-guidelines.

Bui, Quoctrung, Sanger-katz., Margot. “We Mapped the Uninsured. You’ll Notice a Pattern.” The New York Times, October 30 2015. http://www.nytimes.com/interactive/2015/10/31/upshot/who-still-doesnt-have-health-insurance-obamacare.html.

Massey, Douglas, S. Categorically Unequal: The American Stratification System. Russell Sage Foundation, 2005

Moore, Brian, Levit, Katharine, Elixhauser, Anne. Costs for Hospital Stays in the United States, 2012. HCUP Statistical Brief #181. Agency for Healthcare Research and Quality, Rockville, MD, October 2014. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb181- Hospital-Costs-United-States-2012.pdf . ∗

Smith, Jessica C., Medalia, Carla, U.S. Census Bureau, Health Insurance Coverage in the United States: 2014,  Current Population Reports, P60-253, U.S. Government Printing Office, Washington, DC, 2015.