Since election night people have been preoccupied with what the post-election polling reveals about America's electorate, particularly its shifting values and priorities and what this will mean for future elections. A recurring theme among commentators is that growing diversity played an important role for Democratic wins in the Presidential and Congressional races. According to a report by the Pew Research Center, Obama received the support of African Americans, Latinos, and Asian Americans by a wide margin. Women also played a prominent role in this election: they not only supported Obama by a wide margin, but were also instrumental in Democratic wins in the House and Senate. And a Gallup survey showed that voters who identify as gay, lesbian, or bisexual overwhelmingly supported President Obama.
Commentators also point to growing support for important "social" issues like marriage equality and abortion as further evidence of a cultural shift toward a more liberal electorate that is more likely to vote Democratic. For example, while abortion continues to be a divisive issue, exit polling by Fox news showed that 59% percent of those polled believe abortion should be legal in all or most cases, and a Pew Research Center poll showed that Democrats hold a significant advantage when voters are asked who would do a better job representing their interests in this area. The same polls also show more people support same sex marriage than are against it (support ranges from 51% - 49% depending on the poll), and this growing support was reflected in the wins for marriage equality in Maryland, Maine and Washington.
It should go without saying that no group (whether defined by race, gender, or orientation) is monolithic in its values or voting preferences, and individual voters care about a range of issues, and to different degrees, in ways that may not always be easily predictive of one's votes. Nonetheless, politicians, campaign advisers, and political pundits are paying a lot of attention to these trends and asking why these diverse groups' interests have converged to support Democrats this year. One of the best explanations of this convergence that I have read so far was an op-ed titled The Culture War and the Jobs Crisis in the New York Times, by Thomas Edsall:
"More recently, there has been a steady diminution of conflict and a growing consensus on the left culminating in the 2008 and 2012 election victories. Issues now linked – clustered — in the minds of many Democratic voters include not only traditional socio-cultural, moral and racial issues like women’s, minority and gay rights, abortion and contraception, non-marital child-bearing, and the obligation of government to provide a safety net, but also to matters pertaining to the overarching role of government in generating greater social justice. "
I agree that concern about social justice and an appreciation for the government's role in ensuring a more just system is a common thread for these otherwise diverse groups. And I think that the most salient issue this election season that highlights this shared interest is health reform. Health care is an area where "socio-cultural" issues, like discrimination against women, racial and ethnic minorities, gay men and lesbians, and people with disabilities, can have the most tangible, immediate, and devastating effects on one's life. These groups have historically been, and are currently still at high risk of discrimination in a variety of ways. As a result, they are also at greater risk of exclusion from, or discrimination in, a private health care market that is linked to employment, and thus more likely to need government protection or to rely on the public safety net.
Inequity in the Health Care Market: Before Health Reform
Historically, health care access has been determined primarily by powerful private industry players like insurance companies and large employers; predictably, certain groups are at greater risk of experiencing barriers to access. For instance, insurers selling plans in the individual insurance market would charge women higher rates than men or deny them coverage altogether if they were deemed "high risk" - a label assigned to women who were victims of domestic violence or with a prior history of Caesarean sections, according to a recent Institute of Medicine (IOM) report. The IOM has also reported that women and racial and ethnic minorities tend to suffer from chronic disease and disability at greater rates, making them "high risk" and thus more likely to be excluded from the individual insurance market.
People who receive insurance through their employer, rather than on the individual market, have been protected from this kind of inequity for the most part. But access to employment-based insurance is limited. Employees in low-wage and part-time jobs often do not have this option, and according to the IOM, racial and ethnic minorities are disproportionately represented in jobs that do not provide insurance. A study by the Williams Institute reveals that gay men, lesbians, and transgender individuals suffer high levels of employment discrimination, which can impact access. And many workers use employment-based policies to provide health care for their families as dependents, which is not an option for most same-sex couples denied the right to marry.
Even those lucky enough to be insured may be treated inequitably because of coverage exclusions that are not justified actuarially, and which reflect broader patterns of societal discrimination. One example that has received the most attention in health reform is the exclusion of women's reproductive health care, including prescription contraception used to treat medical problems as well as facilitate pregnancy planning. The inability to control the timing of pregnancy has implications for women's and fetal health, but can have particularly serious consequences for women suffering from chronic conditions. Another troubling example includes a history of exclusion of people with HIV from the private market, as well as insurance caps on, or exclusions of AIDS and AIDS-related treatment, that make coverage inadequate. Finally, coverage for mental health care is still not comparable to coverage "physical" health conditions, despite federal and state mental health parity laws. Denials of certain kind of mental health care, especially residential care and long-term habilitative care for people with developmental disabilities, persist despite litigation and regulatory oversight.
Although health care and civil rights advocates have tried using anti-discrimination law to fight inequity, this has yielded mixed results, at best. Public insurance has provided an imperfect, but crucial safety net for some groups excluded from the private market. Federal funding, in particular, has played a critical role in facilitating access to HIV medication, women's preventive and reproductive health care, prenatal care, and habilitative services.
Convergence Around Health Care Justice & the Affordable Care Act
Health care justice cuts across many issues and deeply impacts the diverse groups that are becoming more prominent in national elections. I have already described how various forms of discrimination in society (in employment, marriage, and the health insurance market) create barriers to health care access. Gaps in health care, in turn, have serious consequences for health and life, as well as economic security: access to care helps prevent disabling illness, enables people to manage their chronic conditions, and prevents significant medical debt, a common cause of personal bankruptcy. "Socio-cultural issues", "health" and the "economy" are often treated by pollsters as alternative issues to be ranked during election time, but these things are inextricably linked in pronounced ways for the historically disadvantaged groups which make up a growing percentage of voters.
Moreover, treating women, racial and ethnic minorities, and members of the LGBT community as discrete groups also ignores intersections among these populations that further highlights overlapping concerns around health care justice. For example, 2010 data published by the U.S. Census Bureau shows that same-sex couples are as likely as different-sex married couples to include a racial or ethnic minority, and same-sex couples with a householder who is a racial or ethnic minority are more likely to have children than those without a racial or ethnic minority. A 2008 snapshot of California's Black LGB population provides an even more detailed picture of what this intersection looks like: women comprise a majority of Black people in same-sex couples (55%), almost 55% of Black women and 11% of Black men in same-sex couples are raising children, and Black same-sex parents have fewer financial resources to support their children than those in married couples. Consider the numerous barriers that a Black woman raising children with her same-sex partner must face as a result of the intersection of her race, gender, orientation, and economic status. The harms resulting from those barriers are often compounded as well, either because she has fewer resources to help compensate for these barriers, or because some barriers, like discrimination based on race or orientation, can actually create new health problems, like depression, that exacerbate existing ones.
Health care did play a prominent role in this election. Obama's signature accomplishment from his first term, the Affordable Care Act (ACA), is designed to help remedy much of this inequity. It builds upon the existing public-private patchwork, but tries to plug many of its holes. It strengthens the public safety net by extending Medicaid coverage to the very poor who do not fit the traditional narrow eligibility categories. It also uses regulation to try to level the playing field for people in the individual market to give them similar protections enjoyed by those covered by employment-based insurance, such as guaranteeing coverage, eliminating risk rating, and providing subsidies to ensure access to affordable, meaningful coverage.
Other consumer protections in the ACA either directly or indirectly eliminate some of the inequities mentioned above, especially provisions that eliminate gender rating and caps on lifetime benefits, and require qualified health plans to provide some minimum level of benefits (referred to as "essential health benefits") to ensure that coverage will be meaningful. Federal regulators have already made clear that preventive services must include the kind of screenings and reproductive health care for women that have been excluded in the past, and that people with chronic conditions, like HIV, should be able to get meaningful coverage in the private health care market. Additionally, the ACA requires an external review mechanism to help counter wrongful denials of care, like those frequently seen in mental health coverage determinations. Although the federal government has delegated the responsibility for defining many of these requirements to the states, it has published guidance that acknowledges existing inequities and emphasizes the importance of ensuring equity in coverage.
This is not to say that the Affordable Care Act is perfect or will succeed. In fact, this post is the start of a series of blog posts looking at how the states and federal government handle reform implementation, with a focus on whether the ACA delivers the equity and affordability it promises. But the ACA provides a stark contrast to the alternatives presented by Republican candidates. Promises of repeal by Republican challenger Mitt Romney and other republican lawmakers relied on abstract attacks on "big government" and ignored the critical role that government has played in removing some of the barriers that cause inequity in the private health insurance market. Romney's choice of Ryan as a running mate triggered fears that he would support Ryan's plan to gut the public safety net by transforming Medicare into a voucher program and Medicaid into a block grant program, predicted to result in greater numbers of people becoming uninsured. Finally, political rhetoric that treated abortion and marriage equality as purely "social" or "cultural" issues that conservatives should fight was divorced from any consideration of the economic, personal and health-related hardships that result from marriage discrimination and denial of reproductive health care.
It should not be surprising then that the interests of this more diverse electorate converged to deliver wins for President Obama and other Democrats, especially in light of polls like those by the Washington Post, which show that 81% of the people voting for Obama listed as a "top quality" they want in the President "cares about people like me", and that 75% of Obama voters listed "health care" as a "top issue." Health care is a civil rights issue - not one distinct from other civil rights concerns like discrimination based on racial, ethnic, gender, or LGBT status, but one that is shaped by, and inextricably linked to, the many other kinds of inequity experienced by an increasingly diverse electorate that will continue to shape future elections.