Dying of Whiteness: How the Politics of Racial Resentment Is Killing America's Heartland

Metzl describes a focus group of 12 white men in a housing project in Franklin, Tennessee. Tennessee is a state with a weak “social lattice,” and the housing project is one of the few options for men who have “[fallen] from whatever safety their lives once represented” (127). Most of the men are there because of illness. Lacking private insurance, yet making just enough money ($15,856 a year at the time) to not qualify for Medicaid, they face “insurmountable mountains of medical bills” that have forced them out of their homes (128). While politicians in Nashville debate the implementation of the ACA, which would expand Medicaid to men like those in Metzl’s focus group, the men claim to oppose the ACA because of “cost.” They complain that the healthcare bill is “a waste of our hard-earned tax dollars” (128) and worry it will add to the country’s debt.

One man in the focus group is Tom, a 53-year-old white man who works at a fast-food drive-through. He describes himself as “a ticking time bomb health-wise” (129): He eats junk food, is overweight, and has a family history of high blood pressure. He has suffered two heart attacks and has a chronic cough. While many of Tom’s “life choices and characteristics” are risk factors for chronic illnesses, looking at Tom’s story from “only a medical perspective” fails to account for “the health effects of ideology” that lead Tom to staunchly oppose “Obamacare” (129). On the one hand, Metzl suggests that exchanging money for better health is a logical reason to want money. However, for the white men in Metzl’s focus groups, the fear of cost "also functioned as a proxy for the tensions of race” (130).

Signed into law by President Obama in 2010, the Affordable Care Act was designed to make healthcare in the United States more cost-effective and accessible. The bill included increased access to preventive care, expanded access to Medicaid, and featured consumer protections meant to control costs and prevent insurance companies from denying coverage. The bill was complex, and everyone agreed it was “far from perfect.” However, supporters saw it as an important step to improving “communal safety nets” and improving society-level health.

The ACA faced legal challenges, primarily due to the bill’s “individual mandate” that required everyone above certain income levels to purchase health insurance or face a tax penalty. In 2012, the Supreme Court ruled that the individual mandate was constitutional; however, the court’s ruling also limited the law’s ability to forcibly expand Medicaid. Initially, states were required to participate in the ACA’s Medicaid expansion in order to receive key federal funds. However, the court ruled that the federal government could not “coerce” states into expanding coverage and that Medicaid expansion would remain “optional.”

In theory, people like Tom, whom the ACA was designed to help, would embrace healthcare reform. Especially in a place like Tennessee, where eliminating barriers to healthcare was once an important state goal. Like Missouri’s former prominence in the arena of firearm safety regulations, Tennessee was once a prime example of “progressive approaches to health care for low-income populations” (133).

In the early 1990s, Tennessee launched TennCare, a “novel public-private partnership” meant to expand access to care among low-income Tennesseans (133). Initially, the project was immensely popular and successful, with 1.2 million registrations in the first year. However, the program’s popularity became its downfall: As enrollment soared, so did costs. At the time, Tennessee was also eliminating state income tax and couldn’t afford the high cost of health care. Insurers began to pull out, and the state was forced to begin making cuts to TennCare.

By 2012, the program’s resources had become so limited that low-income Tennesseans were entered into a lottery for available applications. Therefore, Tennessee was in need of the kind of help the ACA was offering. The ACA’s Medicaid expansion would grant coverage to the Tennesseans who “fell through the cracks” of TennCare (135), help the state tackle the debt that TennCare had developed, and allow the state to “deliver on its goal of quality care for all citizens” (135). In theory, the ACA was “like manna from heaven,” but in practice, it was met with “ferocious resistance” (135).

Republican lawmakers in Tennessee claimed the ACA was “simply too expensive.” They opposed the law based on cost and for the bill’s individual mandate. Cost was a legitimate concern for many middle- and low-income people across the United States. As the ACA was implemented, healthcare premiums were reported to go up around the country, and some researchers argued that improved preventative care added additional costs to the healthcare system because people were living longer. This illustrates the unpopular reality that “population-level medical care” is expensive by nature (136).

However, Metzl argues that most leading metrics suggested that people like Tom in Southern states like Tennessee had “little to fear from the ACA” (136). There were federal subsidies to protect lower-income people from premium increases, and many low-income and immigrant populations were able to obtain insurance and avoid expensive emergency room visits. Rather, the obsession with cost was related to “deeper concerns” tied to “the unaffordable and often highly unhealthy American politics of race” (137).

In Tennessee, Metzl and his team recruited men aged 20 to 60 in Nashville and the surrounding areas to discuss various healthcare-related topics. They organized the respondents into groups of 12 to 15, sorting them by race, socioeconomic status, and other ways that “subtly built uniformity into the proceedings” (140). They wanted the men to feel comfortable discussing “their opinions and biases” (140) and sensitive information about their health and wellness, and hoped to study how “white and black experiences with healthcare” differed (141). To further promote group cohesion, Metzl led the white focus groups, and his African-American colleague Derek Griffith led the groups of African-American men. Each group began with a questionnaire followed by a series of open-ended questions about healthcare, health decisions, manhood, autonomy, and health politics.

For much of the 19th century, enslaved African Americans in the US South were insured as property rather than as people. These historical realities meant that healthcare was already a racially-charged topic in states like Tennessee. Other social and health plans throughout the history of the United States also had racial connotations. For example, when Medicare and Medicaid were introduced in 1965, many worried Southern hospitals would have to integrate in order to receive funding. On the other hand, “providing equitable, community-based healthcare” was an important “strategy for advancing social justice” in African American communities (142). Finally, the debate over the ACA was also affected by differing attitudes toward President Obama and his identity as an African American man.

Metzl and his team hoped their focus groups would illustrate “how this gulf in attitudes about health” shaped the men's behaviors and opinions concerning health and healthcare (143). In the first section of the group, Derek or Metzl asked questions about the men’s personal health. The participants generally responded with comments on foods they tried to eat or avoid and exercises that they did or did not do. In this respect, the white men and African American men offered similar responses, “[linking] their health to their own agency, as manifest through what they ate or they did” (145).

Another commonality between the two groups was the reality that “life circumstances” often interfered with attempts to be healthy. This was particularly apparent with lower-income individuals of both races, who often didn’t have access to fresh fruits and vegetables or struggled with external forces like unemployment and depression. When the conversations turned to politics, however, the commonalities between the two groups began to disappear.

About 20 minutes into the focus group, the leader would ask what role the government should play in promoting individual health, quickly changing the mood in the room. In states like Tennessee, mentioning government invokes ideas of the Reconstruction period and “the bitter legacy of the civil rights era” (147), when the federal government threatened the “so-called Southern way of life” (148). Most importantly, questions about the government’s role in healthcare elicited different responses from the white and Black focus groups.

One man, Brian, who had previously claimed he would have died without help from Medicaid and the VA, insisted that the government had no place in healthcare. When pressed on his answer, Brian complained of “long lines, long waits, lost hours” when trying to go to the doctor, implying that “bureaucracy thwarted his authority and autonomy” (149). However, Metzl claims that Brian’s “resistance” came primarily from “dogma.” Brian called the ACA “a form of […] socialism or […] communism” (149), echoing accusations made by conservative public figures like Bill O’Reilly. Another man suggested that some people aren’t sick; they “just use the shit out of [the system]” (149). Another man piped up that people do the same with welfare: Many individuals receiving assistance “[need] to get jobs, quit having children, and really get buckled down” (149). Accusations like these imply that resources are limited, and that some people are using more than their share.

Metzl then shares a lengthy exchange between the men. One man complains that “we” are covering the cost for “the Mexicans” and “the illegal […] mothertruckers” (150). Another man agrees and complains that “Mexicans” are coming to the United States, having babies, and using Medicaid on the American taxpayer’s dollar. Finally, one man comments, “We’re starting to sound like Donald Trump rallying” (151). This conversation occurred in 2016, when Trump’s candidacy “was still seen as a sideshow” (151). However, listening to the focus group, Metzl wondered for the first time if Trump could actually become president.

The men from the group were voicing fears about limited resources that they learned from the disaster of TennCare. They worried that there wouldn’t be enough benefits to go around and saw “themselves […] competing against other disadvantaged persons” (152). In the face of the “evaporating middle class,” whiteness was “the currency through which the men cling to their dwindling benefits” (152). Politicians like Donald Trump then “preyed on these men’s fears,” making American society ever more divisive (152).

Metzl suggests that accusations of socialism and communism also “carried racial implications” as they “connoted the breakdown of racial boundaries and hierarchies” (152). Hearing middle- and lower-income white men in the South express racist and anti-immigrant sentiment was not “hugely surprising,” but Metzl didn’t expect the subject to come out of conversations about health and healthcare. Many of the men in the focus group depended on government assistance for life-saving medical care and medication; therefore, “their expressions of whiteness and white anxiety […] work[ed] against their own self-interests” (153).

These concerns were repeated in every group of white men with whom Metzl and his colleagues spoke. Across income brackets, white men in Tennessee rejected government involvement in healthcare, citing “concerns about autonomy” and about “the cost marginalized others might inflict upon the men in the room” (154).

Due to a history of “firsthand experience with government intrusion and neglect” (157), Metzl reasoned that African American men in Tennessee would be even more skeptical about government intervention. The white men he spoke with often talked about “events they feared might happen” (157), similar to how white gun owners imagined scenarios where they might need to protect themselves from intruders and threats. Black men, on the other hand, “folded their skepticism about government into a broader recognition of social injustice” (157), understanding that they were “already set up for failure” (158) by systemic social injustice.

Even so, some Black men voiced many of the same concerns as white men when discussing government intervention in healthcare. Some even worried that people “gamed the system,” echoing the anxieties that white men shared. However, in contrast to white men’s fear of an unspecified “them,” Black men discussed healthcare “through the language of ‘us’” (159). The Black focus groups discussed the health of African American people as a whole, using words that “connoted communal responsibility” (159).

Accordingly, Black men were markedly less skeptical about the role of the government in promoting healthcare. They often supported the ACA, seeing the expansion of healthcare as “a net benefit” that could improve communal health, strengthen safety nets, and shore up the social fabric of the country. Metzl suggests that the “anxiety” found in the white focus groups represented “a constant pressure to bear and embody the cost of staying on top” (162). Black men, “unburdened by ideologies of supremacy or the invective of fallen greatness” (162), saw healthcare expansion as something that could benefit “all of society.”

Initially, several important politicians supported implementing the ACA in Tennessee. However, in 2013, Tennessee Governor Bill Haslam gave a speech cheered by Tea Party lawmakers, arguing that the ACA was too expensive. Instead of expanding Medicaid, the governor proposed a new plan for Tennessee health reform that was essentially “Obamacare minus Obama.” The plan was popular among Tennesseans and policymakers; however, it too was abandoned amid fears of “cost.”

The financial fears over the ACA were essentially baseless. The federal government would have covered over 90% of the Medicaid expansion, and nonpartisan groups estimated that Tennessee’s healthcare spending would have gone up approximately 2.8% between 2014 and 2022. Additionally, the state stood to see substantial savings on healthcare spending for the uninsured, and Tennessee would have received “a windfall” of federal funds as well as estimated billions of dollars in goods and services. Despite these potential benefits, healthcare reform was “a martyr at the stake” (167).

Metzl argues that the white men from his focus groups gained “group cohesion” through their opposition to the ACA, even suffering from reduced health coverage. Their resistance worked to “guard the old ways” and preserve the “mythical” grandeur of the old South (168). Metzl suggests that “a bit of perverse empowerment accompanied the pain” these men experienced (168). He references historians and literary theorists who argued that enslaved Black people used their broken bodies to refuse “further […] demands of servitude” (169). In this context, Metzl suggests that rejecting the ACA “gave larger purpose to the act of refusing medical intervention” (169). Through their illness and pain, white men were able to affirm “group identity” and their “position in a hierarchy that, while hardly at the top, was not at the bottom” (169). However, rejecting the ACA in Tennessee had a “quantifiable” cost.

Metzl and his team wanted to understand how the refusal to expand Medicaid affected “all-cause mortality” in Tennessee. These rates can change for many reasons, but in theory, healthcare reduces mortality rates because more people have access to preventative care, allowing chronic illnesses to be treated early.

To calculate the data, Metzl and his team performed a “morbid subtraction,” removing deaths after healthcare intervention from the deaths that existed before the intervention. Previous studies tracking Medicaid expansion in states like Arizona, Maine, and New York found a 6.1% decline in all-cause mortality, equaling an estimated 2,840 deaths. These studies formed the framework for Metzl’s own research as he examined how Tennessee’s mortality rates might have been affected by adopting Medicaid expansion.

Metzl’s team took Tennessee’s all-cause mortality rates between 2011 and 2015, then performed a series of calculations meant to project what the data would have looked like if Tennessee had expanded Medicaid. They found that between 1,863 and 4,599 Black lives and between 6,365 and 12,013 white lives could have been saved by Medicaid expansion in Tennessee. Metzl notes that the white focus groups’ fears were true inasmuch as Medicaid expansion “probably helped low-income minority populations more” (175), but there was also a “significant cost” to white populations. To quantify that loss, Metzl and his team calculated how many years of life had been lost due to refusing Medicaid expansion. They discovered that every Black and white adult Tennessean lost somewhere between two and five weeks of life, making “failure to expand Medicaid” a “leading man-made cause of death in Tennessee” (176).

Next, Metzl’s team examined the insurance marketplace in Tennessee by comparing the state to Kentucky, which initially adopted the ACA in 2013. However, in 2016, a new Republican governor pulled out of the ACA insurance marketplace and rolled back Medicaid expansion. Even though Kentucky’s expansion lasted only three years, it formed a contrast to Tennessee. In the first year of the expansion, 10% of the population gained health and health coverage, creating significant gaps in coverage between Kentucky and Tennessee as uninsured rates plummeted.

Metzl and his team also found that people in Kentucky paid less for medical care than their counterparts in Tennessee, weakening the argument that the ACA was “too expensive.” Like his analysis of gun death by suicide rates in Missouri and Connecticut, Metzl imagines the gap between Kentucky and Tennessee’s statistics as representing “the space of politics, brought to bear on the matter of people’s bodies and lives” (182). Had Tennessee chosen to expand Medicaid, that space might have closed upwards toward the line that Kentucky plotted in the years following the ACA. Instead, the gap closed downward after Kentucky repealed Medicaid expansion in 2016. Critics of the ACA argued that “turning bad lines to good ones was not worth the cost” (182). In reality, studies showed Medicaid was “a cost-effective program;” rejecting expansion “would surely decrease taxes for corporations and wealthy people,” but the savings would come at a “potentially devastating cost “to lower-income individuals and families (183).

While Metzl regards the ACA as flawed, studies on the cost of Medicaid showed that states actually saw an average net return of $68,000 per enrollee. The expansion also protected Americans from medical bankruptcies and allowed recipients to contribute more productive work years to the economy. The argument against the cost of the ACA “assumed that health was fair and equitable,” with each individual paying their own way and accepting the consequences of their actions (184). Health is not equitable: Communal factors are also important determinants of health, and “people often get sick despite their attempts to stay healthy” (185). The white men in Metzl’s focus groups wanted to believe they were “the master of [their] own autonomous house” (185). Therefore, “fear about money stood in for anxieties of connectedness in the contexts of health and wellness” (185). Acknowledging the reciprocal nature of cost “would have meant seeing the economy of health as a larger grid” that connected them to minority populations (185).

In this context, cost “functioned as a metaphor for concerns about a system that gravely threatened the sense of individualism underpinning particular white notions of health” (185). Adopting the ACA required white men to envision themselves in a network where their own well-being “depended on the responsible actions of everyone else, including Mexicans and welfare queens” (186). The continued support of politicians who promise to “take away […] health care” might seem to make little sense; however, in the context of the United States’ racial history, the rhetoric is “all too familiar” (187). While claiming “to bolster white privilege,” politicians like Trump “essentially asked lower-income white people to choose less coverage and more suffering” instead of accepting a system that would link them to minority groups and could lead them “To healthier longer lives” (187). Thus, “the policies and sentiments that aim to bolster the identity of whiteness also effectively turn whiteness itself into a heightened, perilous, and ever-more-costly category of risk” (188).