Obamacare and Inequality

Ta-Nehisi Coates has been asking some troubled and troubling questions in the wake of a New York Times analysis of Obamacare showing that the new program could actually increase the disadvantages facing African-Americans because they are so heavily overrepresented among the eight million people who are “impoverished, uninsured, and ineligible for help” thanks to the refusal of states to expand Medicaid.

Coates wonders if Obamacare is another casualty of the collision of high-minded liberal universalism with the realities of race and class in America:

The conventional liberal approach says, “Obamacare didn’t get all we wanted but it got a lot of it. We took what we could.” But what if that logic really does exacerbate the wealth gap? Is it moral to support a program that fails to help those who need it the most? The response might be that — like Social Security — eventually all states will adopt the expansion. But this does not address the damage done in the meantime, nor does it address the possibility in increasing if not the wealth gap then the overall gap in life outcomes.

There is a more radical possibility — Obamacare is ultimately immoral, not because it didn’t get “everything” but because it didn’t get to those who needed it most. The stated impulse of class-first liberalism is that those who need it most — measured by wealth and income — will get the most help. In the case of Obamacare, this may eventually happen, but great damage will be done in the meantime.

Coates later regretted the use of the term “immoral” with respect to Obamacare, but he’s raising a point we need to think about regularly with respect to progressive ends and means–say, when we devote all of our passion to protecting Social Security and Medicare instead of food stamps and Medicaid, which are more important to more people who are in most need of assistance. Yes, “universal” benefits create more politically powerful coalitions than those which concentrate help on the truly needy, but when they actually discriminate against poor people or people of color, it’s hard to justify them as progressive.

In the case of Obamacare, of course, the exclusion of the eight million discussed in the New York Times article was not part of the law’s architecture; it took a Supreme Court decision to create the anomaly of large swaths of the population being too poor to qualify for help. But any program building on Medicaid as it exists has to take into account the extraordinary race-inflected hostility of Republicans, especially in the South, towards people “on welfare,” and figure they’ll do all the damage they possibly can to its effective implementation. This should not be an afterthought.

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Ed Kilgore

Ed Kilgore, a Monthly contributing editor, is a columnist for the Daily Intelligencer, New York magazine’s politics blog, and the managing editor for the Democratic Strategist.