Healthcare and Politics: “Dying of Whiteness”

Eyal Press has produced an article for The New Yorker describing healthcare in the state of Alabama that is both heartbreaking and infuriating.  His work is titled A Preventable Cancer Is on the Rise in Alabama online, and A Deadly Principle in the paper version of the magazine.  The cancer of concern is cervical cancer which is usually caused by the human papillomavirus (HPV) for which there exists a vaccine.  Press provides this background information.

“A century ago, cervical cancer was the deadliest form of cancer among women in the United States. Since then, the prevalence and the lethality of the disease have declined dramatically. The widespread use of Pap smears has allowed doctors to detect abnormalities earlier. And in 2006 the F.D.A. approved the use of the human papillomavirus, or H.P.V., vaccine, which can protect women from the most dangerous strains of the virus. Cervical cancer typically results from H.P.V. infections that are transmitted sexually.”

“Cervical cancer is now viewed by most physicians as preventable, and in more affluent parts of the country it is correspondingly rare. But in the poorer pockets of less wealthy states it remains disturbingly common. According to the American Cancer Society, more than four thousand women in this country will die from the disease this year. Women who develop cervical cancer in Alabama are more likely to die than their counterparts in any other state—and in recent years Alabama’s mortality rate has been rising.”

Press identifies lack of access to healthcare which could prevent the cancer via vaccination or ameliorate it with early detection.  The burden of this cancer then falls most heavily on the poor, and on the rural poor particularly.  A proximate cause for this abysmal performance by Alabama resides in its political decision to not participate in the expansion of Medicaid incorporated in the Affordable Care Act (Obamacare).

“…the 2010 Affordable Care Act…extended Medicaid benefits to all households earning up to a hundred and thirty-eight per cent of the poverty line. But in 2014, when Medicaid expansion took hold, Alabama and twenty-four other states, almost all of which had Republican-led legislatures, opted out; that year, Robert Bentley, then the state’s governor, argued that it would burden taxpayers and foster ‘dependency on government.’ In Alabama, as in much of the South, the Affordable Care Act was derisively called Obamacare, and was attacked as a wasteful government program that showered benefits on undeserving recipients.” 

Who, in effect, would be those undeserving recipients?

“…in Alabama…the income requirements for Medicaid are more stringent than in any state except Texas. In a family of four, a parent qualifies for benefits only if the household income is less than three hundred and ninety-three dollars a month—roughly eighteen per cent of the poverty line.”

The governor essentially ruled that a family with an income greater than 18% was not deserving of any assistance in procuring healthcare.  What have been the results of this political philosophy so persistent among Republicans.

“States that expanded Medicaid under the Affordable Care Act have seen reductions in mortality from kidney failure and cardiovascular disease, along with an increase in early-stage cancer diagnoses. They have also seen lower rates of infant and maternal mortality. A study published last July by the National Bureau of Economic Research estimated that, from 2014 through 2017, states that expanded Medicaid saved the lives of more than nineteen thousand adults between the ages of fifty-five and sixty-four alone. In the states that rejected expansion, the researchers concluded, fifteen and a half thousand lives were lost.”

In addition to direct damage to individuals, this policy produces a feedback mechanism that undermines the basic functioning of the healthcare system.  People who are denied preventive care and treatment of symptoms ultimately fall back emergency wards for assistance.  This places a financial burden on hospitals which must treat these patients without much hope for compensation.  The effect on rural hospitals has been particularly severe.

“Since 2010, fourteen hospitals in the state, more than half of them in rural areas, have closed, forcing women to make long treks to get care. Corporate consolidation and low reimbursement rates from the federal government have contributed to the trend, but another major factor is Alabama’s refusal to expand Medicaid. For years, the emergency rooms of rural hospitals have been inundated with poor, uninsured patients. Hospitals often receive no compensation for treating these patients, which lowers their operating margins and fuels what the Chartis Center for Rural Health has called a ‘closure crisis.’ In February, the organization reported that the eight states with the highest number of rural-hospital closures since 2010 had all declined to expand Medicaid.”

It is critical to recognize that this sorry state of affairs is not an aberration in Alabama politics, it is a consciously designed feature of life in Alabama and of Republican politics.  Since the time of the first instances of black slavery in this country, the political elites in the slave states have played off the tensions between poor whites and blacks to their advantage.  Slavery was very harmful economically for whites who had to compete with slaves as laborers.  They could be held in place by convincing them that they were not really poor because they had the example of black slaves to illustrate their superiority.  Slavery provided the floor to which poor whites could be driven economically in order to keep their wages low.  Nothing has really changed over the centuries.  Slavery has gone, Jim Crow has come and gone, but the political elites still play the same game.  Poor whites are indoctrinated with the notion that that they are superior to blacks and threatened with the possibility that there is a plot to allow blacks to somehow surpass them economically.  Meanwhile, low wages for whites continues to be the basic economic and political strategy.  The only thing that has changed over the centuries is that new minorities have been added to the blacks as threats: Hispanic immigrants, Muslims…

Press provides examples of what this strategy has produced in terms of the politics of healthcare.

“Along with increasing vaccination rates, broadening access to health care is an obvious way to fix the problem. But, in much of the South, a surprising number of the poor and working-class people who would benefit from changing the system are opposed to doing so. A few years ago, Jonathan Metzl, a psychiatrist and sociologist at Vanderbilt, began organizing focus-group discussions near churches and low-income housing projects in Tennessee, which, like Alabama, had refused to expand Medicaid under the Affordable Care Act. At one such meeting, in Nashville, a group of working-class white men were invited to talk about the health-care system. Many of the participants—amputees, men with oxygen cannisters—were in visibly poor health. Some acknowledged having to rely on various forms of assistance to deal with their ailments. ‘I would be dead without Medicaid or the V.A.,’ one man said. But, when Metzl asked about the role of ‘government’ and about programs such as the Affordable Care Act, a man complained that people on welfare with ‘ten and twelve kids’ were abusing the system. Another claimed that ‘illegal mothertruckers’ received all the benefits, and that ordinary Americans were subsidizing them. A flurry of complaints about Mexican immigrants followed, prompting one man to say, ‘We’re starting to sound like Donald Trump’.”

“In 2019, Metzl published a book, ‘Dying of Whiteness,’ in which he argued that people who voiced such views, fuelled by racial animosity and ‘the toxic effects of dogma,’ ended up supporting policies that put their own lives at risk. ‘No way I want my tax dollars paying for Mexicans or welfare queens,’ a white former cabdriver suffering from terminal liver disease told him. ‘Ain’t no way I would ever support Obamacare, or sign up for it. I would rather die’.” 

Once the southern elites were democrats who wished nothing to do with the party of Lincoln.  However, famous race baiters like Nixon and Reagan declared that the Republican Party was a better home for racists, and demonstrated that the racist tropes would work well with whites in other regions as well.  The Republican Party of a few generations ago no longer exists.  Its heart is now in the former slave states and it has no interest in fostering racial, social, or economic justice, or even in democracy as a form of government.  Trump is the culmination of decades of political evolution.

When you cast you next ballot (probably by mail) remember that republicans are not worthy opponents with slightly different perspectives, they are an enemy out to destroy your way of life.  They must be defeated—every last one of them.