The recently passed Inflation Reduction Act (IRA) of 2022, which is headed to President Joe Biden’s desk this week, is historic and unprecedented. In addition to making the most significant investments in the country’s history to address climate change, it also includes health care provisions that will meaningfully improve the affordability of health insurance and prescription drugs for millions of Americans. But one of the massive health care coverage concessions made during the negotiation process came at the expense of Black Americans; sacrificing certain demographic groups for the sake of political feasibility is not a new feature of the American policymaking process.
In 12 states, an estimated 2.2 million people are uninsured because they have no accessible health insurance options. People in the “Medicaid coverage gap” have incomes that are too high to qualify for Medicaid, but too low to qualify for premium assistance for Affordable Care Act (ACA) marketplace plans. Advocates have been sounding the alarm about this problem since 2014. And researchers have been beating the drum for at least as long, putting out study after study that underscore the positive effects of Medicaid expansion.
Not lost on these advocates and researchers is that states that have not expanded their Medicaid programs, mostly concentrated in the south, have some of the largest shares of Black people. States decisions’ about whether to expand follow a legacy of racialized politics.
Some claim that lack of expansion is merely a financial decision. It doesn’t hold water. When Medicaid expansion through the ACA first became an option, the federal government was paying 100 percent of the costs associated with the expansion population. While this has since dropped down to 90 percent, the American Rescue Plan Act of 2021, the economic stimulus package signed into law last March, included an additional financial incentive to get the remaining states to expand. Moreover, studies show that Medicaid expansion under these terms is a financial benefit to states.
The Biden Administration ran on addressing the Medicaid coverage gap. The Build Back Better Act, which was passed by the House in November 2021, contained a (temporary) approach. It would have allowed people in the gap in non-expansion states to qualify for subsidized marketplace coverage through 2025. But this fix was not included in the newly passed IRA.
Why not? Let’s look at the politics.
Democrats had been trying to get this reconciliation package passed for over a year. To secure Senator Joe Manchin’s (D-WV) vote, they had to prioritize deficit reduction and strike certain provisions. But the health care coverage provisions that they chose to exclude would’ve had an outsized impact on Black people in particular. In addition to excluding a fix for the Medicaid coverage gap, policymakers also dropped the permanent expansion of postpartum Medicaid coverage, which would’ve required all states to extend Medicaid coverage for pregnant people from 60 days postpartum, up to a full year. This provision had the potential to meaningfully improve life outcomes, particularly for Black birthing people, who are three times more likely to die from pregnancy-related causes (52 percent of which occur up to one year after birth) than their white counterparts.
The exclusion of Black Americans from federal policy deals, ostensibly on the basis of political and administrative feasibility, is not new. In his book, Fear Itself: The New Deal and Origins of Our Time, Dr. Ira Katznelson explains how the systemic exclusion of Black people from the bedrock of the American welfare state — the Social Security Act of 1935 — occurred under the guise of political feasibility. To reach a deal with southern Democrats, agricultural and domestic workers were excluded from the Social Security and unemployment insurance programs. Over sixty percent of Black workers fell into these groups. In fact, as he documents in one of his other books, When Affirmative Action Was White: An Untold History of Racial Inequality in Twentieth-Century America, many of the key federal policies designed to promote economic opportunity during the New Deal era up until the modern Civil Rights Movement, like the GI Bill, gave white people a leg up and effectively left Black Americans out.
During the debate on the reconciliation bill, Senator Raphael Warnock of Georgia, where over a quarter of a million people do not have health insurance because the state has refused to expand the program, introduced an amendment to address the coverage gap. Only five senators (Baldwin, Collins, Ossoff, Sanders, and Warnock) voted to consider the amendment.
Before the debate (in the Senate) on the bill began and any amendments were introduced, several Democratic senators came out and said they would be voting no on any and all amendments, because they would distract, divide, and put the rest of the bill at risk; they said they did not consider this amendment to preserve the rest of the bill.
That may have been true — with the introduction of this fix, Democrats may have lost the votes, eliminating the bill’s political pathway to law. But choosing to sacrifice the same group of people, time and time again, sends a message about who we value and who we do not. Policy decisions will always entail tradeoffs, and negotiations will always include concessions. But when policy concessions continually come at the expense of the same group of people, it’s not reasonable to conclude it’s a coincidence. It’s reasonable to consider that it’s a defining feature of the political system.
Research for this piece was supported by Arnold Ventures.