The Battle For Medicaid: Welfare or Entitelement?

By Amanda Grigg

The term entitlement wasn’t used regularly in American politics until the 1980s, when Ronald Reagan began using it frequently – likely to avoid uttering that-which-must-not-be-named (Social Security). Today the term is almost inescapable, especially during debates over the deficit (and probably for the same reasons that Reagan used it). By complaining about “entitlements” politicians can talk about popular plans like cutting spending and lowering the deficit without explicitly mentioning cutting popular programs like Social Security.

People talk about entitlements when they talk about the deficit because entitlement programs make up the majority of the federal budget (about 60% in proposed 2013 budgets), because entitlement programs tend to be large and have steady growth, and because they have a privileged place in the budgetary process. Sometimes when people say entitlements they mostly mean this: relatively large federal benefit programs whose spending is mandatory and not subject to traditional budget cuts.

But entitlements are defined by much more than their size and budgetary restrictions. The term also tends to refer to the most beloved anti-poverty programs in the country, and some of the only social support programs whose benefits are both widely recognized and respected.

art.medicareNotably, entitlement programs are also characterized by  a sense of the public’s right to access them (a fundamental difference between entitlements and programs people refer to as “welfare”). That’s why people can say “don’t cut MY Social Security/Medicare/Medicaid” without sounding crazy (keep your government hands off my Medicaid is another story). Beneficiaries feel entitled to these benefits and thus entitled to raise a major stink over any proposed cuts (something that traditional “welfare” beneficiaries haven’t done en masse since the 1970s).  This is exactly the kind of attitude Arkansas was trying to avoid when it included language explicitly denying entitlement to Medicaid in recent legislation passing the Medicaid expansion. As sponsor Senator Jonathan Dismang explained, “The point of this language is to ensure that the individual does not think he has a perpetual right to the program.”

In his Democratic National Convention speech in 2012 former president Bill Clinton aimed to do the opposite, framing Medicaid as an entitlement by emphasizing  the high proportions of Medicaid spending on groups associated with entitlements (the elderly and the middle class). He highlighted Medicaid spending on nursing home care for the elderly and reminded the audience that, “A lot of that money is also spent to help people with disabilities, a lot of middle-class families whose kids have Down syndrome or autism or other severe conditions.” Similarly one of Medicaid’s champions in Congress, Rep. Harry Waxman has said that as a result of expansion ““we’ll see a whole lot of grateful Americans, and a whole lot more support for Medicaid, in areas where it has traditionally been scorned as a poor people’s program.””

There is a clear battle brewing between those attempting to reframe Medicaid as a middle class entitlement akin to Social Security, and those like Arkansas Senator Dismang and Paul Ryan (among many others) who are fighting to keep Medicaid in the category of welfare (or welfare-ish) spending. Why is this worth fighting over? Well…

Welfare scholars have long argued that in the US, the social groups a program is associated with and whether or not a program is thought of as an entitlement (which are closely related) have enormous consequences on its structure and public image. The US is generally agreed to have a stratified or dual track welfare system with a superior track (entitlements) and an inferior track (need-based benefits often called “welfare’) characterized by deserving/undeserving beneficiaries, contributory/noncontributory programs, and rights-based and need-based programs. The generosity of the historically white, male entitlement track has repeatedly been contrasted with the limited benefits of the female and minority-dominated need-based track in order to demonstrate the raced and gendered origins of welfare. These traditionally male-dominated entitlement track programs include Social Security and Social Security Disability Insurance (SSDI) as well as Veterans Benefits. They are often referred to as upper track programs because they offer more generous benefits and are (quite problematically, as feminists suggest) much more popular among the public. These programs are federally administered, with relatively stable nationally uniform requirements. In the case of Social Security, a mythology has developed to assert that recipients are only getting back what they paid in and are thus certainly “owed” and deserving of their benefits.  Traditionally female and minority-dominated need-based programs include Food Stamps, Medicaid, and Aid to Families with Dependent Children (AFDC). After the welfare reform efforts of the 1990s, AFDC was replaced with Temporary Aid to Needy Families or TANF, the program people generally refer to when speaking (generally derogatorily) of “welfare” – though in fact many of these lower track programs no longer fit the definition of welfare (cash assistance to the poor that doesn’t require them to enter into any institution, including the workforce, in order to receive it). These programs tend to be less generous in the amount and form of benefits offered, and much less popular among the public, which makes them more vulnerable to benefit cuts. They rarely offer cash assistance and often include demanding application processes and extensive surveillance of recipients.

tumblr_mby0uuATEu1rwkx4nPopular dislike for need-based programs and respect for entitlement programs supports the maintenance of significant structural differences between the two tracks. Individuals are much more likely to support generous benefits for groups they deem deserving. Thus discourses that misleadingly label welfare recipients undeserving, Cadillac-driving “welfare queens” (and often invoke race and class biases and stereotypes) direct public support toward less generous, more restrictive welfare programs for the poor (i.e.the ever-popular drug tests for welfare recipients). This helps to explain why entitlement programs tend to have extremely limited supervision, relatively generous benefits and unlimited benefit periods, while need-based programs considered “welfare” tend to have extensive supervision and declining benefits with lifetime limits.

In the 25 states (and counting) embracing the Medicaid expansion, beneficiaries now include groups like recent college grad, retirees who don’t yet qualify for Medicare and people between jobs, many of whom are firmly middle class. It makes sense that supporters would see an opening in these changes in Medicaid’s beneficiary demographics since demographics have traditionally been closely tied to which track of welfare a program is on. And it’s no surprise that supporters of Medicaid are trying to squeeze it into that sweet sweet entitlement bubble, or that critics are so opposed to this that they’re legislating the meaning of Medicaid – it (really) pays to be on the right side of the tracks.

Race Biology Follow Up: Larry Bartels on Genopolitics

By Amanda Grigg

Apparently Larry Bartels and I have mind melded (I think that means I get tenure) because he also posted about genetics yesterday. More specifically, he posted about “genopolitics” which, yes, is a thing.

For those interested, The Scientific American gets into the gritty scientific details in a piece called “Why Genes Don’t Predict Voting Behavior.” 

Back to Bartels, he comes to a conclusion that I think is similar to, if slightly more conservative than my take on the value of certain kinds of genetics. In this case it’s genetic research aimed at predicting political behavior, but I think the argument could apply equally well to my last post about biological race and genetics:

My argument is not that genetic explanations of political attitudes and behavior are infeasible (though they are sure to be extremely difficult to achieve) or illegitimate (though it is easy to imagine them being harnessed to unsavory political ends). It is simply that the real scientific payoff does not look worth the effort.

So for those of you not convinced that race isn’t at least a little genetic, there’s still reason to question the value of (and even oppose) this kind of research. Of course I would add that in the case of biological race and genetics, the acceptance of the assumption underlying the research also does real harm to racial minorities. And, perhaps worst of all, it puts you (at least a little bit) on the side of jerks like Craig Cobb.


*Image credit: Dan Saelinger

Laughing at White Supremacists: Race and Bad Science

By Amanda Grigg

A video has been making the rounds in which Craig Cobb, a white supremacist who was leading the charge to create a neo-Nazi enclave in North Dakota undergoes a DNA test for a talk show, only to find out that he is “14% sub-Saharan African.” As of this post it has 120,000 views on youtube and has been featured on  TheGrio, The Daily Mail, The LA Times and The Huffington Post, where it is described as (maybe) “the best thing ever.”

Of course everyone loves the video. It bears a striking resemblance to what is probably Dave Chappelle’s best sketch of all time, about a blind white supremacist named Clayton Bigsby who doesn’t know he’s black. But in this case it’s a real white supremacist, so there’s the added bonus of social justice schadenfreude at watching him get his comeuppance.

As someone who studies health politics I find this video wildly annoying. Why, you ask?

It’s portraying Cobb as a villain for thinking race is biological and then proving him wrong by using science to tell him what his biological race is. It’s essentially accepting his presumptions of race as biology and racial purity to prove that he isn’t racially pure. But…race isn’t biological. And perpetuating the idea that it is is a way bigger problem than some racist nut out in North Dakota repeatedly being barred from creating an all-white town.

What is biological race? Well, according to the zoological definition, it exists when you can distinguish a group of organisms based on genetic difference. Humans of what we think of as different “races” do not differ anywhere near enough genetically to be distinguished in this way. And even our socially created definitions of race have differed dramatically across time – so a Craig Cobb of 100 years ago might have been even “more” black, because Southern or Eastern European ancestry might have been included in his black tally. As recently as 1930, these results would have made Cobb 100% “negro” according to the US census’s “one drop rule,” which asserted that anyone with “one drop of Negro blood” was considered black. Does it seem like this is getting silly? That’s because race biology is.

This isn’t just an issue of bad science, biological understandings of race do real harm to racial minorities, particularly in the healthcare system. Take for example, spirometers, which are used to measure lung function. They’re actually calibrated to account for a presumed difference in black and white lung capacities (with black capacity presumed to be 10-15% lower). Some even have a switch for “race” built in. The problem? These assumptions are based on bad race-biology science and they aren’t accurate. As a result, black patients have to be sicker to get the same treatment, not to mention to qualify for worker’s comp or insurance/compensation for their illness.

Assumptions about biological race can also lead to delayed or incorrect diagnoses, as in the case of a young black girl whose cystic fibrosis – a disease predominantly associated with Caucasian patients – went undiagnosed for years until a passing doctor, glancing at only her x-ray, asked her primary physician “who’s the girl with cystic fibrosis?”

Thinking about race in this way also shapes how we understand the causes of disease. With the rise of genetics, biological/genetic race is increasingly studied as a possible cause or risk-factor for disease. This goes on despite the fact that – and here I have to quote someone who understands genetics better than I do – “the environmental conditions that interact with putative polymorphic variations to trigger the onset of disease, not those variations themselves, would likely be the targets of intervention (or the cause of disease per se).”

Not surprisingly, this focus on genetics can obscure the social and environmental causes of many race-based disparities in health. As Dorothy Roberts explains:

“A renewed trust in inherent racial differences provides a convenient but false explanation for persistent inequalities despite the end of de jure discrimination. It is also the perfect complement to social policies that implement the claim that racism has ceased to be the cause of African Americans’ unequal status.” (Dorothy Roberts, Fatal Invention, 64)

The acceptance of race biology via genetics also means money is spent on finding race-specific genes when it could be more effectively spent treating the condition or addressing known (often social/environmental) causes and risk-factors. Conditions like hypertension and asthma for example, have repeatedly been linked to racial minorities’ greater exposure to stress and pollution. Still, genetics labs are established purely to identify the gene that’s causing high rates of asthma among black and Puerto Rican youth. Peer reviewed studies in medical journals have linked postpartum depression to poverty, lower levels of education, a lack of social support, and stress, all of which are more common among women of color. So of course in 2013 the National Institute of Mental Health funded a million dollar study aiming to identify the “biomarkers” for postpartum depression in African American women.

To wit, race isn’t biological, let’s stop talking/acting/researching/funding as if it is.

For much much more on this check out one of my favorite books by one of my favorite scholars: Fatal Invention by Dorothy Roberts

For a shorter read on race Biology, check out this May 2013 article by Merlin Chowkwanyun in The Atlantic

Obromacare or MotherbroXXX

By Amanda Grigg

Last week everyone from The Atlantic to Buzzfeed covered a new Colorado Obamacare campaign targeting “bros.” The campaign can be found at “ and is part of the Thanks Obamacare campaign run by ProgressNow Colorado and the Colorado Consumer Health Initiative. You can also reach the site via “” which is, clearly, a more bro-friendly url.

got insurance, bro?

Of course the Colorado campaign’s real aim is to get the attention of healthy, uninsured young people, a group that pretty much everyone agrees is essential to the success of the Affordable Care Act. Because they rarely use medical services these “young invincibles” are cheap to insure, and thus their enrollment is necessary to offset the costs of older, less healthy patients. It just so happens that most of the healthy, uninsured young people (57%) are male. This explains both Obromacare and the Koch brothers’ recent attempts to get bros to “opt-out” via events at campus bars offering free beer and ipad drawinngs. Unfortunately for proponents of the ACA, healthy young men without pre-existing conditions are generally thought to benefit the least from Obamacare, which makes them both vital and possibly resistant to health care form. As a result, we get to watch as everyone and their mother (literally) bro-down.

AARP_ACA_eCard7_600.imgcache.rev1379416663982Efforts to promote the health care law among young invincibles have also targeted mothers. Ads on facebook and recipe websites admonish, “Mom knows best, get insurance!” and cheeky AARP e-cards read “Get health insurance so I can stop pestering you to sign up and start pestering you to get married.” As Democratic pollster Celinda Lake explained to the Washington Post,“it will be the moms of America who are going to decide if their families get coverage…They will decide and then insist their children and husbands sign up.” Polling backs Lake up – many young uninsured people, and particularly young men, cite their mothers as their most trusted source of information about the health care law.

So, a big part of the explanation for these ads can be found in policy and the fact that high enrollment among healthy, uninsured young men is necessary to make Obamacare work. The campaigns are highly gendered because they’re targeting very specific, gendered audiences (mothers and young men). And they’re a little cheesy because bureaucrats and the Koch brothers trying to identify with the cool kids is a little like your parents trying to talk to you about Miley Cyrus. Or your great aunt publicly chastising you for posting on facebook because “who would do that to a cat?”

More troubling than the seemingly inevitable pandering to bros is the misleading use of healthy young men as an exemplar of the harms of health care reform. Because of their unique relationship to the ACA, healthy 25 year old men have become the darlings of health care reform critics, who have conveniently held them up as (purportedly) randomly chosen example that illustrate how the healthcare law works and why it will raise rates (Jonathan Chait does a good job of addressing the problems with this tactic). Put simply, the 25 year old healthy male example is a poor one on which to base arguments about the ACA generally because it’s one of very few cases in which individuals may see rates go up, and because the group makes up a small portion of the total population. And as Sarah Kliff explains, the structure of the ACA makes it difficult to generalize even about this relatively small, homogenous group. Most notably, the example is misleading because it’s almost inevitable that in his lifetime this bro will benefit from Obamcare both directly and indirectly if he gets sick, becomes poor, lives past 25, cares about anyone who is or becomes sick, and let’s not even get started on how straight men benefit from the birth control mandate.