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How repealing Obamacare could splinter neighborhoods

"Inequality brings out the worst in us."

In the early 1990s, one of Florida's most populous counties had a problem.

So many uninsured residents were using the public hospital that it was costing the county more and more money.

But unlike other communities suffering the same fate, Hillsborough County had a unique solution.

Local leaders were able to pass a half-cent sales tax increase to give health care services to about 30,000 uninsured residents. And 25 years later, the program is still going strong.

So health care advocates tried to bring this policy to other communities.

But they kept running into similar problems: People with insurance didn't see it as priority to use public funds to create a safety net for their less privileged neighbors.

This is a tension that exists in many local governments. But when Obamacare was passed, it lifted some of this burden.

Sure, it was billed as a policy that would make individual people healthier — and it ended up insuring 20 million people. But it also made neighborhoods healthier. It meant communities no longer had to fight over local tax dollars to care for the uninsured. It also meant there were fewer uninsured people who felt cast out and dehumanized by their communities. It lifted up our poorest and most vulnerable neighbors.

So when Republicans talk about repealing Obamacare, they promise to replace it with something better — and much of the talk is about individual health and cost, even though both the House and Senate plans would insure fewer people and shift the burden disproportionately to the poor and sick.

But it’s not just a uniquely “personal” issue, as Texas Sen. Ted Cruz said at a debate on Obamacare a few months ago. It’s not just about individual bodies, though it may seem that way.

Rather, health care is so personal and the stakes are so high that it affects the way we view our community — and the way we view our neighbors.

Research shows that high rates of uninsurance tears at the fabric of a neighborhood. It makes the uninsured feel dehumanized; it makes residents feel like their neighbors are less trustworthy and benevolent. Instead of blurring the differences between people we see on a daily basis, it brightens them. And some research even suggests that as we're exposed to these signs of impoverished people in our communities, we become less willing to help them. We become less generous.

What it does to a neighborhood: a decline of cohesion

Last year, Vanderbilt University researcher Tara McKay looked at about 2,000 families in Los Angeles who had responded to neighborhood surveys in the early and mid-2000s.

The survey asked five questions on how cohesive they felt their neighborhood was:

Then McKay analyzed how people's answers differed based on the percentage of uninsured people in their neighborhood, after controlling for other factors that might affect these answers.

She found that rates of uninsurance were one of the best predictors of how cohesive a neighborhood was, and that overall, a higher rate of uninsurance tended to make a neighborhood less cohesive.

These surveys, conducted in 2001 and 2007, were from before Obamacare. But how did neighborhood cohesion levels change with Obamacare?

The researchers projected the effect; the dotted purple line below hints at what likely happened when Obamacare was signed into law in 2010:

In other words, the way we feel about our neighbors is heavily influenced by whether or not people in the community have the means to get medical care.

"We've been talking about this as a health policy," McKay told me, "but, really, there are these social and economic consequences."

What it does to the community: a splintering along economic interests

Even in Hillsborough County, which is the gold standard for local health care programs, not everyone was happy about raising taxes to give social services to the poor.

Early on, two wealthy businessmen led a fight that argued the county was giving out "free health insurance" — and that this "misguided public generosity" would attract uninsured people from around the country. (It didn’t.)

But this tension between the haves and have-nots makes perfect sense in communities with high levels of inequality. It means not only that people have different desires of how they want to spend public funds but also that people have a very different expectation of life — and even the longevity of life.

A recent study led by Stanford University researcher Raj Chetty found that in some communities, the difference in life expectancy between the poorest residents and the richest residents is almost 10 years. You can see what the disparity looks like in your county by using this tool below:

While this doesn't look at who is insured or uninsured, it shows that these stratified communities have to make decisions about the mortality of their residents. If Obamacare is repealed and replaced with something that lowers the safety nets, that disparity will only rise.

This has a larger impact on our cohesion levels in local communities than it does on our cohesion levels in larger geographies, like counties or states.

We see this in McKay's research, where she looks at whether high uninsurance levels at a county level have an impact on how we feel about our neighbors. What she finds is that it isn't nearly as strong as when we're exposed to inequality in our neighborhoods.

What it does to the uninsured: dehumanization

But this is also about how health care providers react to uninsured people. "They close emergency rooms or relocate emergency rooms out of places where they're exposed to uninsured,” McKay says. She also cites research that shows providers in these areas offer lower-quality care.

This means concentrated communities of uninsurance not only lack the means to pay for care, but they also lack access to it.

“It shapes the way they see the community," McKay says. They start thinking about who the community values and internalize that.

This is especially true of immigrant communities, which are more vulnerable to falling through the cracks.

In 2012, researcher Taewoo Kim wanted to understand why Korean immigrants were one of the least insured communities in the country. So he conducted in-depth interviews with 48 first-generation Korean Americans with legal status.

What he found was devastating.

Korean Americans were often small-business owners surviving on tight margins and extremely long hours. They experienced high levels of physical and emotional stress, but they felt the American health care system — especially its payment system — was largely inaccessible to them.

The researchers found that within the community, there were "widely circulated stories of financially devastating medical bills” that made health care institutions unreachable for Korean Americans.

Almost half of those interviewed did not have insurance.

For a period of my childhood, this was my family; we owned a dry cleaning business, then a car stereo shop, then a vending machine business. My parents worked extremely long hours, much of it physical labor, with barely a moment to care for their own deteriorating bodies.

One 54-year-old man, who had spent more than half his life in the US, framed our mindset perfectly in Kim’s study. He told the researchers:

There is no such a thing as check-up for us. The hospital is a place where we go when we feel pain, isn’t it? If I have health insurance, it would be a different matter. But even the American insurance system is not good. American insurance often has a one thousand or two thousand deductible. Who would buy it? It’s too expensive.

What it does to the privileged: erosion of generosity

Obamacare is ultimately a redistributive policy, so closes the inequality gap between haves and have-nots. So when it’s taken away, it’s likely to accelerate the rise of inequality:

Either directly or indirectly, this means we’re brightening the lines between the haves and the have-nots. This means more people are exposed to inequality on a daily basis — and the question then is: How does this affect our thinking?

It’s something Harvard University researcher Melissa Sands often wondered when she lived in New York City and rode subways filled with people from varying ethnic and socioeconomic backgrounds.

So last winter, she devised an experiment to test this out. She and her research assistants set out to the streets of two affluent Boston neighborhoods and posed as petitioners.

Then they asked every third person to sign one of two petitions: to increase a tax on millionaires, or to reduce the use of plastic bags.

But within 20 feet of this interaction, Sands had an actor pose as either an affluent person or a poor person, denoted by clothing and actions. (There are several ways researchers have "operationalized" exposure to inequality, and this was her way.)

The findings are counterintuitive.

When people were exposed to inequality, they were less likely to sign the petition increasing the millionaire tax. For the plastic bag petition, people signed it at about the same rate.

Also interesting is that the respondents, who were mostly white, were least likely to sign the tax petition when exposed to the poor white actor. Sands said one reason might be that people attributed the black person’s impoverishment to structural racism, but they didn’t believe the poor white actor had any excuse.

But this fell in line with other research that shows exposure to inequality makes people less likely to support policies that help marginalized groups.

For example, one study showed that ethnic diversity in local government made the entity spend less on social services; another showed that being exposed to Spanish-speaking students on the train made people more anti-immigrant.

"Studies like those and studies like mine point to this idea that there are antisocial effects of inequality," Sands told me. "Inequality brings out the worst in us."

An attack on neighborhoods

We often talk about how Obamacare insured 20 million people, but the data showed that it disproportionately helped poor households:

And it disproportionately helped nonwhite households that previously had difficulty accessing health care:

So it’s easy to cast Obamacare as a policy that was designed to redistribute resources to lower-class Americans. But what this research shows is helping marginalized people helps everyone live in better neighborhoods and be around more cohesive communities.

It’s easy to see how health insurance helps individuals, so that’s often where the political fight is. But that means politicians don’t talk about how cutting these safety nets could fracture neighborhoods.

They don’t talk about how it forces an already dehumanized population to fight with their neighbors for the means to care for themselves.

They don’t talk about how it would brighten the lines between the haves and have-nots — between those who can afford to take care of their bodies and those who can't. Or how exposure to inequality make privileged people hunker down, away from those with damaged bodies.


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