A Prescription for Continued Inequality: The Affordable Care Act in the Context of the Long-term Evolution of the American Welfare State

Abstract

On June 28, 2012, in National Federation of Independent Business v. Sebelius, the Supreme Court ruled that federal compulsion of state Medicaid eligibility requirement expansions was unconstitutional. It was this ruling, evocative of deep-seated American federalist ideals that compromised the ultimate scope and trajectory of the Affordable Care Act by altering its implementation. Essentially, it resulted in state Medicaid expansion being left as a state option – allowing states to opt in or opt out based on particular state policy preferences. As such, varying state Medicaid expansion decisions confirmed that the Affordable Care Act would not live up to its original promise because healthcare access would not be available as a right to all citizens. It would be subject to states’ expansion decisions. The resulting disproportionate disparities among low-income black American adults in states that have yet to expand Medicaid coverage in particular, presents the motivating problem that this evaluation attempts to address. Furthermore, this evaluation’s motivating research question is the following: why does the Affordable Care Act, enacted in part to address the aforementioned disparities in healthcare access, in implementation, end up further perpetuating historical healthcare access disparities among black Americans? This evaluation hypothesizes that one explanation for why the Affordable Care Act’s implementation, as modified by the 2012 NFIB v. Sebelius Supreme Court ruling, deviates from it’s philosophical goals and origins, and thus results in the disenfranchisement of black Americans specifically, is because it is unable to overcome the patterns of disparities, often further entrenched by political maneuvers like federalism and identifying deserving versus undeserving poor, that have become inherent to and codified by the evolution of the American welfare state from its inception to today. As such, this evaluation confirms the above hypothesis by first quantifying significant health outcome, healthcare access, and healthcare coverage disparities among black American adults specifically, confirming the significance of state Medicaid decisions on the enfranchisement of this historically disadvantaged population. After confirming these disparities, this evaluation turns to support its sociopolitical and historical hypothesis as to why these disparities exist, by surveying, curating, and constructing a unique evaluation of important historical, sociological, and political science texts related to the construction and evolution of the American welfare state. This all provides the necessary scholarly and evaluative insight to apply this analysis’ original hypothesis to the Affordable Care Act. After supporting its primary hypothesis with sociopolitical and historical data, this analysis turns once more to the modern day implementation of the Affordable Care Act to explore the policy implications of this evaluation, in order to suggest key considerations for the future. As such, this evaluation contributes significantly to current scholarship by applying a historical and sociopolitical analysis to current disparities in healthcare access as a result of the modified scope, implementation, and trajectory of the Affordable Care Act.