Dog Whistle Politics

(W)e have got a tailspin of culture, in our inner cities in particular, of men not working. And just generations of men not even thinking about work or learning the value of work, and so there's a real culture problem here that has to be dealt with.

                                                                                       Rep. Paul Ryan (D-IL)

The 2012 Republican candidate for Vice President made this comment Wednesday (March 12) on Morning in America, a radio talk show hosted by Reagan administration Secretary of Education and compulsive gambler Bill Bennett. He followed it up the next day at the Conservative Political Action Committee convention with a denunciation of the school lunch program.

You don't need a secret decoder ring to interpret the message in Ryan's latest remarks. Later that day, Rep. Barbara Lee (D-CA) released this statement:

Ryan's comments about “inner city” poverty are a thinly veiled racial attack and cannot be tolerated. When Mr. Ryan says “inner city,” when he says “culture,” these are simply code words for what he really means: “Black.”

Ryan defended himself by saying, “This has nothing to do whatsoever with race. It never even occurred to me.”

Two weeks ago, I posted some candid remarks by the late Republican campaign manager Lee Atwater, a primary advocate of the “Southern strategy.” Atwater pointed out that, in the 1950s, it was considered acceptable for politicians to appeal openly to the racial fears of White voters. However, by 1981, it was necessary to use more “abstract” language, such as favoring “states' rights” or “cutting taxes.”

Ian Haney Lopez, a law professor at the University of California at Berkeley, has a new book, Dog Whistle Politics, about the history and current relevance of race-baiting in political campaigns. (I haven't read it yet; I have it on order.) He uses the metaphor of the dog whistle since it is inaudible to the human ear, but reliably influences the dog's behavior. Dog whistle political appeals seem on the surface not to be about race, but they are understood as racial by White voters. The fact that these statements refer to something else gives the politician plausible deniability when he or she is accused of racism. Here is Dr. Haney Lopez discussing his book on Democracy Now.

In recent years, the Republican Party's domestic political message has become almost synonymous with symbolic racism. It is intended to persuade White Americans that social welfare programs primarily benefit urban Blacks and other minorities, and that the overrepresentation of Blacks among the poor is due to lack of motivation to work. Government is portrayed as stealing their hard-earned tax dollars and giving them to lazy poor people. But the people influenced by this message are actually voting contrary to their economic self-interest, since, when elected, Republicans pass policies that primarily benefit the wealthy. These government policies have been the primary cause of the large increase in inequality that has occurred over the past 30 years.

Ryan's remarks imply that poverty is largely an urban phenomenon, but that is not the case. These data from the U. S. census show that the poverty rate is higher in rural areas—not coincidentally, the Republican base.

It is also not the case that a disproportionate amount of tax money goes to minority recipients. The Congressional Budget Office reports that while African-Americans make up 12% of the population and 22% of the poor, they only receive 14% of government benefits. Non-Hispanic Whites, on the other hand, are 49% of the poor and receive 69% of government benefits.

Black unemployment can best be understood as a result of lack of opportunity, specifically, the disappearance of industrial jobs from urban centers, and well-documented hiring discrimination against African-Americans. The Republican "culture of poverty" message is an obvious attempt to blame the victim. (See my earlier post on this important social-psychological concept.)  

Ryan's response to criticism of his “Blacks are lazy” comments illustrates the role of plausible deniability in dog whistle politics. On the one hand, given Ryan's prominence in the Republican Party, it is totally implausible that his remarks were thoughtless or unintentional. The Southern strategy is Campaigning 101 for Republican candidates. Yet the corporate media accept his denials without skepticism. In fact, they almost never call out Republicans for race-baiting. Could it be because Ryan's budget proposals, which call for cutting social spending and reducing taxes on the rich, coincide with the policy preferences of the small number of wealthy owners and managers of the corporate media?

You may also be interested in reading:

A Racist Who Loved the Blues

And Then There Were Five, Part 1

Blaming the Victim

The Revolt of the Nones, Part 2

Before continuing, please read Part 1 of this post.

What are the reasons for the rise of the nones? The media often propose some variation of a political backlash model, suggesting that organized religion has alienated young people with its stance on a cluster of issues related to sexuality and the family—divorce, contraception, abortion, gay rights, and the status of women. And in fact, the nones hold more liberal views on all of these issues. For example, 72% of them believe that abortion should be legal in most or all circumstances, while 53% of the population hold that view, and 73% support same-sex marriages, compared to only 48% of the population. However, these attitudes could be a result rather than a cause of their secularism, or they could all be caused by other social conditions.

Cross-cultural research on the sociology of religion has emphasized two predictors of religiosity, poverty and lack of education. The Existential Security Framework proposes that objective measures of security, such as material wealth, good health and a government-provided safety net, encourage secularity. When people lack these forms of security and can't do much about it, they turn to superstition as a way of asking for help.  Comparing countries, there is a strong positive relationship between poverty and religiosity. Non-believers are concentrated in European countries such as Sweden (64%), Denmark (48%), France (44%) and Germany (42%). On the other hand, fewer than 1% of people from Sub-Saharan Africa are non-believers. However, the United States is one of the richer countries that bucks this trend. In addition, this model may be better at explaining the worldwide decline in religiosity than changes here in the United States, since real wages in this country have been stagnant for the past 30 years.

If poverty is religion's friend, its worst enemy is probably education, especially insofar as it encourages scientific literacy and critical thinking. Data from Canada indicate that, holding other variables constant, each additional year of schooling results in a 4% increase in the likelihood that a person reports no religious affiliation. Braun attempted to find out which was the best predictor of secularism, education or economic security. He assembled 149 objective measures from some or all of the world's 193 countries. He grouped them into clusters of related measures with the help of factor analysis. He then used multiple regression to determine which measures were most strongly related to survey questions about the importance of God and religion in one's life.

He found that education was the strongest predictor of lack of religiosity, and that economic security had no additional effect when education was held constant. It's important to note that multiple regression is just an advanced form of correlational analysis. These data do not mean education is the cause of secularism, economic security or any of the other variables in the analysis. It merely indicates that education accounts for more of the variability in religiosity than any of the other measures that were available. 

Once again, the United States is an outlier in that we are more religious than our average level of educational attainment would predict, and the positive relationship between years of schooling and non-belief is weaker than in other countries. My own hypothesis, unsupported by data, is that political interference in the public schools prevents American teachers from referring to religion in any but the most favorable terms. Even at the college level, attempts to discuss critical thinking sometimes lead to complaints to administrators from religious students. (It's possible to lecture on critical thinking without mentioning religion, but students usually recognize that critical thinking is pretty much the opposite of religious faith and this invariably comes up in discussions.)

Whatever the reason for the shift, if the nones continue to increase, it is likely to benefit the Democratic Party in national elections. Here are the exit poll data from 2012, broken down by religion.

However, before you members of the Jackass Party break out the champagne, two words of caution:

• The nones make up 20% of the adult population but only 12% of the voters. One of the challenges for Democrats will be to mobilize this group.
• The 2012 presidential race probably overstates the effect of religion on voting, since Barack Obama was one of the candidates. Not only are religious people more likely to be conservative, they are also significantly higher in racial prejudice.

You may also be interested in reading:

The Revolt of the Nones, Part 1

Poverty Causes Harsher Moral Judgments

The Revolt of the Nones, Part 1

A couple of years ago, a neighbor and I chatted about the weather while walking our dogs. The topic of climate change came up. He said he agreed with his minister, who had told him that global warming was nonsense. After I began to tick off some of the evidence, he reversed direction and said he welcomed extreme climate change, since it would bring about the “end times.” He and his co-religionists would ascend to heaven, where it is presumably air conditioned. Of course, this is just an anecdote, and it could be misleading, but in this case it's not. I thought about it when I read some recent surveys reporting the rise of the “nones.”

The General Social Survey (GSS) is pretty much the gold standard in American survey research. Not only is the sample representative, but they have a response rate of 70% and 83% of their interviews are conducted in person. The interviews average 90 minutes apiece and respondents are paid $20. Since 1972, the GSS has been asking: “What is your religious preference? Is it Protestant, Catholic, Jewish, some other religion, or no religion?” The percentage answering no religion has gone from 5% in 1972 to 20% in 2012 (the most recent survey). Here's the trend line. 

Since 1990, those preferring no religion have been increasing by .6% per year. These data are consistent with the results of other national surveys.

So the priests are losing ground to the nones. Does this mean the nones are discarding their old habits? Not exactly. Rather than individuals changing their attitudes, we're seeing a demographic transition, as older, more religious people die and are replaced by younger, less religious folks. Here's the 2012 data sliced by age. In the 18-30 age group, also known as the “Millennials,” more people are choosing the secular option than either Protestant or Catholic.

Here the attitudes of these same 18-30-year-olds regarding the existence of “God” are compared to older folks.

What are the reasons for the rise of the nones? Please see Part 2.

You may also be interested in reading:

The Revolt of the Nones, Part 2

Poverty Causes Harsher Moral Judgments

Poverty Causes Harsher Moral Judgments

You might expect poor people to be more sympathetic toward criminals and other transgressors, since they experience some of the same economic and social stressors as the people they're judging. However, the present research finds low income people to be more harsh in their moral judgments. Two French psychologists, Marko Pitesa and Stefan Thau, propose an explanation for this result.

The authors suggest that people who lack financial resources feel more vulnerable to the potentially harmful behavior of others, since they are less able to cope with victimization. For example, in the case of theft, a poor person will have more difficulty replacing the stolen objects than a richer person. Their harsher moral judgments, then, can be seen as a self-protective response by which they hope to reduce the threat of their own victimization by punishing perpetrators severely. Notice this argument only applies to offenses that do real material harm to someone, but not to victimless actions.

Public Execution in Iran, 2013
© hriran.com

The hypothesis was tested in two studies. The first utilized data from over 85,000 residents of 56 countries participating in the World Values Survey. The respondents were asked to evaluate eight harmful behaviors, such as lying and cheating on taxes, on a scale from “1” (“never justifiable”) to “10” (“always justifiable”). The two measures of economic vulnerability were the participants' self-reported household income, and the rate of inflation in their country. The effects of five control variables were statistically eliminated: education, occupational status, subjective social class, religiosity and race.

Both economic variables had significant effects. Lower income people and people living in countries with high inflation were more negative in their judgments of people who misbehave. In addition, inflation only made a difference when the respondents were poor. The effect of inflation was only statistically significant for people whose incomes were in the bottom sixth of the income distribution.

Of course, these are all correlations, and uncontrolled variables could be responsible for them. What I like about this paper is that they followed up the survey with a controlled experiment. A representative sample of 203 Americans partcipated on the internet. The researchers subtly manipulated the participants' perception of their own wealth by having them indicate their monthly income on an 11-point scale. They varied the anchors on the scale. In the material-resources-lacking condition, “1” was labeled “$0-$1000” and “11” was labeled “over $500,000” (a month!). Obviously, most participants circled numbers near the low end. In the material-resources-not-lacking condition, the scale anchors were “$0-$50” and “over $500.” Most participants were at or near the high end of the scale.

Participants then read five scenarios of either harmful behaviors, i.e., assault, or victimless actions, i.e., masturbation, and rated how “wrong,” “blameworthy,” “inappropriate” and “unacceptable” they each were. The victimless actions were included to ensure that participants who felt economically deprived didn't simply become more negative toward all behaviors.

As expected, the subjects who felt subjectively poorer were harsher in their judgments of the harmful behaviors than those who felt relatively well off. However, there was no difference between the two groups in their evaluations of the victimless actions. A further analysis showed that the relationship between financial insecurity and harsher moral judgments was mediated by feelings of vulnerability (but not by any of the other mood and personality variables that were collected).

When I started reading this article, I thought it might shed some light on the psychology of religion. We know that religiosity is higher in the world's poorest nations, and feelings of vulnerability seem like a plausible explanation. However, I would expect religiosity to be associated with more punitive moral judgments of victimless transgressions as well as those with victims. The experiment finds that lack of material resources only causes harsher judgments of actions that do real harm to victims.

You may also be interested in reading:

Deadbeats for Self-Reliance

The Coverage Gap: The Real Failure of Obamacare

Right now, the corporate media are focused like a laser on the “scandal” of the malfunctioning of the national health insurance exchange website. Although these glitches reflect negatively on the Obama administration, they are technical problems that will be fixed. They have nothing to do with the substance of the law. A more important failure is the number of people, particularly poor people, who will remain uninsured after the Affordable Care Act (ACA) is implemented. This is not the fault of the act as written, but is the result of the Supreme Court decision on its constitutionality and intractable opposition from Republican politicians.

An October study by the Kaiser Family Foundation (KFF) estimates that 5.2 million non-elderly adults living below the federal poverty level (FPL) will remain uninsured in 2014 because they live in the 26 states that—at the time of the study—had declined to participate in the Medicaid expansion. These states are concentrated in the South and West and are controlled largely by Republican governors and legislatures. About half of Americans, but 58% of America's uninsured working poor, live in those states. Pennsylvania is among them. Our Medicaid expansion status is uncertain, but even if the Corbett administration reaches agreement with the federal government on an expansion plan, it is unlikely to be implemented in 2014.

To review, of the approximately 30 million people who were expected to be insured for the first time under the ACA, fully half of them—the poorest half—were to be insured through Medicaid expansion. Traditional Medicaid is jointly administered by the state and federal governments. Federal law requires that all children be covered if their family makes less than the FPL. Children under six are covered up to 133% of FPL. The eligibility rules for adults are determined by the states. In most states, adults without children don't qualify no matter how poor they are. The income level at which parents with dependent children qualify for Medicaid varies from a low of about 20% of FPL in the least generous states to a high of 133% is the most generous states. (In Pennsylvania, it is 46%.)

The ACA expanded Medicaid by making everyone—children and adults—eligible for Medicaid if their family income is 138% of FPL or less. Since this is expensive, the feds agreed to pay most of the cost: 100% in 2014, dropping to 95% in 2017 and 90% in 2020. The ACA required states to implement Medicaid expansion. If they refused, the federal government threatened to withhold its contribution to traditional Medicare—about 57% of the cost. However, this clashed with the conservative majority of the Supreme Court's long-term goal of rolling back federal regulation of the states. In National Federation of Independent Business v. Sibelius, the Supremes decided that the Medicaid expansion rules were coercive and that states may opt out. This denies medical care to many of the Americans who need it most, people who fall into the coverage gap.

The ACA provides subsidies, on a sliding scale, for people individuals and families whose income is between 100% and 400% of FPL. The coverage gap consists of those people, living in states that do not expand Medicaid, who are not poor enough to qualify for Medicaid in their state, but whose income is below 100% of FPL, the level at which the subsidies kick in. This is illustrated in the chart below.

As noted, poor and uninsured Americans tend to be concentrated in the “red states” that are not expanding Medicaid. Twenty percent of the people in the coverage gap live in Texas, and another 15% live in Florida, followed by Georgia with 8% and North Carolina with 6%. At present, 6.8% of the residents of states that are participating Medicaid expansion are poor and uninsured, but 9.1% of the residents of the refusing states are poor and uninsured. The chart below shows the breakdown of the poor and uninsured by race, and shows that Medicaid expansion has a discriminatory impact.

	Live in States Expanding	Live in States Not Expanding
White	40%	60%
Black	32%	68%
Hispanic	51%	49%
Asian	70%	30%
Total	42%	58%

These are America's working poor. By occupation, the folks most likely to be poor and uninsured are (1) cashiers, (2) construction laborers, (3) housekeepers, (4) cooks, and (5) waiters and waitresses.

At the time the ACA was passed, single payer advocates noted that the ACA provided less than universal coverage. The largest excluded group is undocumented immigrants, but the ACA also excludes native Americans and people who are incarcerated, have a religious objection, or can prove financial hardship. To that we must now add 5.2 million working poor Americans, a target group that the ACA was clearly intended to help. These people are being left to die for lack of health care. It will be interesting to see whether they respond at the ballot box when they realize what their state politicians have done to them.

Single payer health insurance is needed now more than ever.

You may also be interested in reading:

A Clouded Vision, Part 1: The Stick  (See both parts)

Tom Corbett to PA's Working Poor: "Drop Dead!"  Part 1  (See all four parts)

The Friday Morning Quarterback

Tom Corbett to PA's Working Poor: "Drop Dead!"

Part 3. What Medicaid Expansion Would Mean to Pennsylvania

On Tuesday, PA Governor Tom Corbett stated that at this time he cannot recommend accepting $38 billion in federal funding to expand Medicaid, thereby denying medical assistance to more than 700,000 Pennsylvanians. This series of posts will consider the implications of that decision. My first post presented evidence that Medicaid improves health and saves lives. The second examined the costs and benefits of Medicaid expansion under the Affordable Care Act (ACA). This time, I'll look at how these costs and benefits apply to Pennsylvania.

I attended a webinar on Corbett's budget sponsored by the Pennsylvania Budget and Policy Center on February 6. Some of the figures in this post come from that discussion. If it becomes available on the web, I will add a reference to it.

First of all, let's look at the 719,000 Pennsylvanians who will be denied coverage. Pennsylvania is one of the least generous states in the country when it comes to providing Medicaid coverage for adults. To qualify for coverage you must make 46% of the federal poverty level or less. For a family of three, that's less than $8781 per year. (You'll recall that children under six are covered up to 133% of the poverty line, and older children up to 100%.) If the governor had agreed to Medicaid expansion, all adults (and children) would have been eligible for Medicaid if they made up to 133% of the poverty level—$25,390 for a family of three.

This is where it gets complicated. Under the ACA, people who make between 100% of the poverty level ($19,090 for a family of three) and 138% are eligible for subsidized health insurance purchased through the federal exchange. (Pennsylvanians will be using the federal exchange because Corbett has refused to implement a state exchange.) This subsidy should, in theory, reduce the cost of private insurance to approximately what they would pay in Medicaid premiums and co-payments. However, this leaves a huge coverage gap for Pennsylvanians making between 46% and 100% of the federal poverty level. They will not be eligible for either Medicaid or subsidized private insurance.

These are the 719,000 adult Pennsylvanians who will be denied health care coverage as a result of Corbett's decision. In effect, Corbett has created a new “doughnut hole” for Pennsylvanians making between 46% and 100% of the poverty level. Most of them fall into the category of the working poor. These are the people who work at Walmart or McDonald's. The graph below illustrates this problem. You can click on it to expand it.

The Kaiser Family Foundation has estimated that Medicaid expansion is worth $37.8 billion in health care coverage for Pennsylvanians to be paid by the federal government between 2014 and 2022. The governor gave as his main reason for refusing the coverage that it will cost Pennsylvania $4.1 billion to implement the program between now and 2022. Most of this is backloaded, when the state is required to cover 5% (in 2017) or 10% (in 2020) of Medicaid costs. This $4.1 billion figure is contested. Kaiser puts it at $2.8 billion. The governor has not realeased any data to show how he arrived at his figure. However, even if it turns out to be accurate, the governor is turning down $38 billion in order to save $4 billion.

Furthermore, this neglects other costs to Pennsylvania if it rejects Medicaid expansion. For example, it is estimated that, if Medicaid is not expanded, Pennsylvania hospitals will be faced with $1 billion per year in uncompensated costs for the care of uninsured people. Some of these costs are shifted to people with insurance through higher premiums, or are paid for by state and local taxes.

In Governor Corbett's letter to Health and Human Services Secretary Kathleen Sibelius, he gives two other reasons for rejecting Medicaid expansion in addition to the alleged $4.1 billion cost.

He refers to the current Medicare as a “broken system” plagued by waste and fraud, and states that it makes no sense to expand such a system. He claims that in 2009, $43 billion “could not be traced directly back to Medicaid beneficiaries.” He does not cite a source and I'm unable to evaluate this claim.

He also calls for granting states greater flexibility “to successfully reform and build a system that works for them.” He calls for aligning benefits “to meet individual needs and closer (sic) resemble coverage provided by employers.” He calls for a Medicaid program that “promotes personal responsibility” and provides “appropriate incentives for participants to seek and retain employment.” This is vague, but bear in mind that Pennsylvania is already one of the country's stingiest Medicaid states. It appears that Corbett wants the flexibility to reduce coverage below the amounts specified in the ACA, or to place some time limit on Medicaid enrollment.

Next time, I'll speculate a bit about the politics of Medicaid expansion in Pennsylvania, and what health care activists can (and cannot) do to persuade the governor to change his mind.

You may also be interested in reading:

Tom Corbett to PA's Working Poor:  "Drop Dead!" (Part 1)

Tom Corbett to PA's Working Poor:  "Drop Dead!" (Part 2)

Tom Corbett to PA's Working Poor:  "Drop Dead!" (Part 4)

States of Confusion

Medicaid expansion is a critical part of the Affordable Care Act (ACA). Of the approximately 30 million people who are currently uninsured, but will be if the ACA is fully implemented, fully half of them—the poorest half—will be insured through the Medicaid expansion.

Traditional Medicaid is jointly administered by the state and federal governments. The Feds set some basic rules. All children are covered if their family makes less than the federal poverty level. Children under six are covered up to 133% of the poverty line. But the states set the eligibility rules for adults. In most states, if you don't have children, you can't qualify for Medicaid no matter how poor you are. In states like Texas and Louisiana, parents only qualify for Medicaid if they make less than 40% of the federal poverty level—$4850 a year for two parents with a single child. Other states are more generous. Massachusetts, thanks to Romneycare, covers all adults up to 133% of the poverty line. But on the whole, Medicaid as currently implemented is not much of a safety net for the poor. Right now, the federal government pays on average 57% of the cost of traditional Medicaid—between 50% and 75%, depending state eligibility rules.

The ACA expands Medicaid by making everyone—children and adults—eligible for Medicaid if their family income is 133% of the poverty level or lower. This is expensive, so the Feds agreed to pay most of the cost. In 2014, they will pay 100%. This drops to 95% in 2017, and to 90% in 2020. Notice that states that whose current Medicaid eligibility rules are relatively stingy—which tend to be the states with the highest percentage of uninsured citizens—stand to gain more money per capita when from the Medicaid expansion than states whose eligibility rules are generous. Texans will make out like bandits if they accept the money, while Massachusetts residents will get nothing, since they are already covered up to 133% of the poverty line.

This is another example of a little-known source of inequality in our national politics. As I previously pointed out, conservative states—states that are more rural, have a lower median income, and tend to vote Republican—receive more money back from the federal government than they pay in taxes. Liberal states get shortchanged. In fact, you could argue that much of U. S. domestic policy involves a redistribution of income in which the “blue states” subsidize the “red states.” (Note: They're not grateful.)

Enter the Supremes. The ACA required states to implement the Medicaid expansion. If they refused, the federal government threatened to withhold its contribution to traditional Medicare. Chief Justice John Roberts, in National Federation of Independent Business v. Sebelius, ruled that this was coercive, and that the states may opt out of Medicaid expansion. Six Republican governors have already said that they will refuse to comply, and several others are threatening to do so. Here is the map. The chart below it shows that, with the exception of Wisconsin, the states that plan to refuse the Medicaid expansion have a higher percentage of uninsured citizens, or in other words, have more to gain from it. This will not only frustrate the intent of the ACA, but will deny medical help to many of the Americans who need it most.

To make matters worse, some Republican governors have announced that they are exploring the possibility of dropping out of traditional Medicaid as well. They interpret the Supremes' decision to mean that they can opt out of any federal program that requires the states to pay part of the cost. The states' reaction to Medicaid expansion makes it very clear that attempting to implement health care reform at the state level is an exercise in futility.

The usual reason given for why conservatives refuse to expand Medicaid is said to be conservative ideology. This is most charitably described as opposition to big government, but when applied to health care, it sounds suspiciously like an unwillingness to help one's fellow citizens who can't afford medical care, either because they are poor or because their family is struck by catastrophic illness. Are there rational reasons for refusing to expand Medicaid?

• The 5% (in 2017) to 10% (in 2020) of the cost of Medicaid expansion is not exactly pocket change. States may be justifiably worried about the cost.
• The “woodwork effect.” Many Americans who are eligible for Medicaid in their state don't apply for it. They may think it's not worth the trouble. However, the publicity surrounding the Medicaid expansion and the threat of a fine for violating the individual mandate may persuade more eligible people to sign up. The states will then be on the hook for whatever part of the cost they would have had to cover under traditional Medicare.

Many health care policy experts, however, think that the financial logic of expanding Medicaid is strong enough to overcome any resistance due to ideology. Here are some of the points they make.

• Not only will it be difficult for states to turn down “free money,” the citizens of those states that turn down the Medicaid expansion will be paying for it anyway through their federal taxes. Their money will go to other states that have accepted the deal (partially reversing the flow of money from blue states to red).
• As noted above, the states whose governors have been most vocal about opting out of Medicaid expansion are the ones that stand to gain the most from it, since they have a higher percentage of uninsured citizens.
• Uninsured citizens in these states will continue to show up at hospital emergency rooms. Their care will be paid for through cost shifting. Costs are shifted in several ways.
• Some of the cost is paid by those who have health insurance. Their premiums are higher in order to pay the cost of treating people without insurance.
• Part of the cost is paid for through federal, state and local taxes, which provide emergency health care for the poor. The Urban Institute estimated that in 2008, state and local governments spent $10.6 billion dollars providing emergency care for the uninsured. However, beginning in 2014, the federal government will no longer subsidize emergency care, so the burden will fall more heavily on state and local government. This cost alone will probably be greater than the cost to the states of Medicaid expansion.
• Finally, part of the cost is shifted to hospitals through what is called “forced charity”—uncompensated medical care for the uninsured. (Of course, they get some of this money back by charging you or your insurance company $28 for a box of tissues while you're in the hospital.)
• Low income citizens and the public interest groups that represent them will protest the denial of coverage to hundreds of thousands of poor and sick people. However, research at the federal level shows that the attitudes of poor people have either no influence, or a slight negative effect, on public policy. This is probably true at the state level as well, but this remains to be demonstrated.
• Most importantly, hospitals and doctors were expecting to have many more customers due to Medicaid expansion. They've already agreed to reduce their reimbursement rates under the ACA, in anticipation of these higher profits. They're   also not happy about forced charity. Health care providers are powerful lobbying groups who spend a lot of money paying off governors and state legislators. They won't take this loss of revenue lying down.

What will happen? Nothing, until after the election. Given how unpopular the ACA is, anything the Republicans can do to resist it now will probably help them in November. If Romney defeats Obama and the Elephants gain control of the Senate, it's probably all over for health care reform for at least a decade.

If that doesn't happen and the ACA survives, it seems inevitable that all the states will eventually agree to expand Medicaid. However, that will take a long time and a lot of people will die while they're waiting for it to happen.