Identifying the Undeserving Poor: The Effect of Racial, Ethnic, and Anti-Immigrant Sentiment on State Medicaid Eligibility

ABSTRACT

In the United States, race and racism are woven into the very fabric of the welfare state. Racial antipathy has undermined public support for benefits perceived as favoring African Americans and has resulted in significant cuts in programs for the poor. Recently, some studies have found that public discussion on immigration has linked attitudes toward Hispanics and illegal immigrants with preferences toward programs once overwhelmingly influenced by racial attitudes. Building on this literature, the present study assesses the effect of racial and ethnic attitudes on state policy outcomes. Specifically, we examine Medicaid eligibility criteria for four categories of beneficiaries, ranked by level of perceived deservingness. We find that eligibility limits are most generous for children, followed by pregnant women and parents. Benefits for “other adults” (low-income non-parents aged 18–64) are subject to more stringent eligibility criteria or entirely unavailable. In contrast with the limits for other groups, the primary attitudinal predictors of Medicaid eligibility limits for the “other adults” category are antipathy toward Blacks, Hispanics, and illegal immigrants. These results confirm that perceptions of deservingness are a central component of U.S. social policy and demonstrate that material policy outcomes – not just policy preferences – are substantially shaped by attitudes toward Hispanics and immigrants as well as African Americans.

KEYWORDS:

• Medicaid
• race
• ethnicity
• public opinion

Acknowlegement

We thank Joane Nagel and John Myles for helpful comments on an earlier draft of this manuscript. Support for this study came from a research grant from the Scholars Strategy Network.

Disclosure Statement

No potential conflict of interest was reported by the authors.

Notes

1. Not all Medicaid eligibility groups are included in the data. For example, the data does not include people who are eligible on the basis of federal waivers. The data also excludes adults over 65 who are eligible for Medicaid because they have spent down their assets on institutionalized care. We do however find that these eligibility groups for which data is available effectively capture differences in perceived beneficiary deservingness.

2. Earlier estimates of state liberalism required responses from many national surveys to be added together in order to produce reliable estimates at the state level. This approach is laborious but effective for estimating state liberalism since liberalism questions are nearly ubiquitous in national opinion surveys. However this approach does not lend itself to estimating other types of opinion less commonly assessed in national surveys.

3. Respondents are given four prompts and asked their level of agreement: “Irish, Italians, Jewish and many other minorities overcame prejudice and worked their way up. Blacks should do the same without any special favors.” “Generations of slavery and discrimination have created conditions that make it difficult for blacks to work their way out of the lower class. [reverse coded]” “Over the past few years, blacks have gotten less than they deserve. [reverse coded]” “It’s really a matter of some people not trying hard enough; if blacks would only try harder they could be just as well off as whites.” Responses are combined into an additive index.

4. The liberal-conservative ideology item asks, “I’m going to show you a seven-point scale on which the political views that people might hold are arranged from extremely liberal to extremely conservative. Where would you place yourself on this scale, or haven’t you thought much about this?”

Additional information

Notes on contributors

Daniel Lanford

Daniel Lanford researches the relationship between people and health policy. His current work focuses on Medicaid and health policy in the wake of the Affordable Care Act. His work spans disciplines and is published in leading journals in sociology, political science, and public health. His work sheds light on the relationship between policy, power, racial conflict, and health policy.

Jill Quadagno

Jill Quadagno is Emeritus Professor and Research ASsociate in the Pepper Institute on Aging and Public Policy at Florida State University. She is the author of 12 books and more than 70 articles on social welfare, aging, and health care. She is past President of the American Sociological Association and a member of the National Academy of Medicine.