The Institution of American Slavery and the Efficacy of the Affordable Care Act

This study investigates the relationship between slavery and the efficacy of the Affordable Care Act (ACA) in the American South. The results from Causal Forests approach reveal het- erogeneous treatment effects of the ACA-Medicaid expansion, with larger reductions in unin- sured rate concentrated in counties with low cotton suitability measures. In Medicaid-expansion states, counties more reliant on slavery experienced lower reductions in uninsured rate following ACA, primarily driven by lower Medicaid coverage among poor Whites. Conversely, no dis- proportionate reductions in uninsured rates are observed for Black Southerners. The evidence suggests that current political preferences, as explained by determinants of slavery such as cot- ton suitability and malaria stability indices, serve as a pathway linking the influence of slavery to the health reform. Moreover, the impact of slavery is attenuated in counties that underwent faster mechanization in the mid-1990s. Overall, findings imply that the legacy of slavery has hindered the implementation of ACA in the South.