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Tesler (2012) also finds, using experimental techniques, that health care policies are significantly more racialized when attributed to President Obama than when they were when attributed to Clinton's reform proposals in 1993–94.Although these findings are very important, one cannot assume that racialized opinion about the ACA carries over to the Medicaid expansion since the public seems to view the Medicaid expansion as separate and different from the ACA overall.Indeed, underlying the Supreme Court's claim that the federal ACA Medicaid mandate was too coercive is the invocation of states' rights and the fundamental belief that states should be able to exercise democratic accountability, thereby responding to citizen desires.Yet, while Americans value the benefits of democratic responsiveness that a federalist structure helps attain, several studies confirm that welfare policies enacted and implemented at the state and local level are racially biased (Soss et al.
Most importantly, there is evidence that when the size of the black population increases and white support levels are relatively low, the state is significantly less likely to expand the Medicaid program.
While there are numerous historical accounts that explicate how the development of the US health care system has been racially biased, there is recent evidence that public opinion about health care reform has become more racially polarized.
In particular, using survey data, Tesler (2012) documents that the racial gap in support for public insurance—with whites being much less supportive than blacks or Latinos—has significantly widened over time.
Work by Lax and Phillips (2012) and Pacheco (2011) also highlights the importance of analyzing policy-specific public opinion.
Lax and Phillips (2012) estimate state-level support for thirty-nine policies across eight issue areas and find that state policy decisions are strongly associated with policy-specific opinion, much more so than a measure of state liberalism or another more general proxy for public opinion.
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National public opinion polls, for example, report consistently higher levels of support for the Medicaid expansion than support for the ACA overall.