The Former Oppressive Racial Regime and Geographic Discontinuities in Efficacy of the Affordable Care Act in the American South

This paper provides evidence of stark geographical discontinuity in efficacy of implemen- tation of the Affordable Care Act (ACA) based on the former oppressive racial regime in the American South. White Southerners’ sentiment to repeal ACA is concentrated in states with more oppressive regime. Following the reform, Medicaid eligibility increased disproportionately in less oppressive states among both White and Black Southerners. This increased Medicaid coverage and lowered uninsured rates among White Southerners, while no such patterns are observed among Blacks. The findings from Arkansas indicates that the reduction in uninsured rate following the Medicaid expansion varied discontinuously within the state, favoring counties in low slavery dependent region. Additionally, across border regression discontinuity design con- firms that counties in less oppressed states benefitted sharply from the reform compared to the adjacent counties on the other side of the border. Moreover, political preferences during the Jim Crow era can explain ACA’s efficacy. Overall, the study argues that deeper roots of racialization of ACA can be traced to the former oppressive racial regime in the American South.