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

by Jonathan M. Metzl

Men often tell you what church they go to when they introduce themselves (“Born and raised here in Murfreesboro, and I go to First Baptist Church, me and the wife too”). A bravado of what sociologist Michael Kimmel calls Southern “muscular Christianity”—crucifix necklaces and forearm tattoos, elaborate facial hair—abuts formal mannerisms and a “yes, sir” or “’preciate that” in every reply. A somewhat contradictory relationship to authority also manifests: men decry government or elitist interference or colonization in one breath and express deep brand or corporate loyalty (“I love my McDonald’s”) in the next.

Many of the men we spoke with saw their health as largely dictated by their own actions or inactions. To what extent is your health within your control? we asked. Men of both races generally linked their health to their own agency, as manifest through what they ate or what they did.

The narratives of lower-income men in particular reflected how larger structures, such as institutions or economies, shaped health outcomes far more than dietary practices or individual choices.

“How do you manage?” I asked. “Well, I’m broke,” he replied, “and I would be dead without Medicaid or the VA… I mean, people are without any kind of health care and they’re going to die. And… I don’t think certain drugs they should charge as much as they charge and probably even be free.” Brian clearly understood how he benefited from Medicaid and VA programs, but when the word government—without specifying state, federal, or other—entered the conversation, he decried intervention or assistance. “No government, no way.”

We are the guardians of our own health, the group mentality implied. But socialism and communism undermine us, cost us, and ultimately link us… to them. The narrative then constructed barriers of inside and outside. If you was born here, the message conveyed, with here implying not just the United States but also the white, anti-communist South, then you was born here.

“Yeah,” added a man who owned a lawn-care service. “A lot of the people that I know that are in poverty are not healthy… the vast majority of them are very overweight, and the children are overweight.” “And how do you know they’re not healthy?” I asked. “Well,” the man continued, “just by their physical appearance, generally speaking, although you can look at their facial expressions, their faces and look at the coloring of their skin, that type of thing.”

In other words, where white men reacted astringently to the thought of “intervention” into health care, black men saw health care “expansion” as a net benefit and government as a fail-safe, albeit a far from perfect one, against predatory illnesses, persons, or corporations.

This certainly appeared to be the case for white men, whose anti-government ideologies created crystal-clear categories of us versus them. We define us by what we have, these groups implied, and we define them by the fact that they want what is ours.

President Obama detailed as much in a press conference three months after passage. “Would you want to go back to discriminating against children with preexisting conditions?” he asked while announcing the ACA-linked Patient’s Bill of Rights. “Would you want to go back to dropping coverage for people when they get sick? Would you want to reinstate lifetime limits on benefits so that mothers… have to worry? We’re not going back. I refuse to go back.”1

These claims were patently false. As lawmakers well knew, the federal government would have paid a whopping 93 percent of the costs of Medicaid expansion until 2022 and no less than 90 percent of the cost of covering people made newly eligible for Medicaid on a permanent basis.

On myriad levels, white men gained group cohesion by “fighting back” against health care reform or retaining their own notions of status and privilege, even as they themselves suffered from conditions that required medical assistance.

In an age of outsourcing and globalization, this resistance became one of white men’s remaining marketable skills, deployed to guard the old ways through modes of resistance and self-sacrifice that made them perfect consumers and foot soldiers for the Tea Party, the National Rifle Association, and the Trump campaign.8

Such correlations are not meant to downplay very real hardship and loss. Rather, they suggest that Southern white medicalized suffering occurred within historical and ideological frameworks that allowed white men to interpret ACA resistance in way that gave larger purpose to the act of refusing medical intervention. Pain affirmed group identity and a position in a hierarchy that, while hardly at the top, was not at the bottom either. No amount of Yankee logic, information, or public health would change that. Safety nets, provider networks, and other grids linked lower-income white men to onetime subordinates turned perceived competitors. Untreated pain, in this one sense, could be read as gain—or at least a victory for stasis.

After extensive analyses, the research group found that expansion led to “significant decrease in mortality during a 5-year follow-up period, as compared with neighboring states without Medicaid expansions,” particularly in adults between the ages of thirty-five and sixty-four, minorities, and low-income persons—an age range roughly comparable to the men in our groups. The authors ultimately found that all-cause mortality declined by a whopping 6.1 percent, or 19.6 per 100,000 people, after expansion, including a 4.53 percent decline for white residents and an 11.36 percent decline for nonwhite residents. Sommers concluded that “2840 deaths [were] prevented per year in states with Medicaid expansions” compared to similar states that rejected expansion.1

On an aggregate level, Tennessee’s failure to expand Medicaid potentially cost every single adult black and white resident of the state somewhere between two and five weeks of life. If this estimation in any way represents reality, then it places “failure to expand Medicaid” on a continuum among leading man-made causes of death in Tennessee.

Studies show a roughly 25 percent higher risk of death among uninsured persons when compared with privately insured adults. Insurance does not by itself prevent or cure diseases. However, we found a related phenomenon in our study of the available data: not only did people in Kentucky have more access to physicians and medical care compared to Tennesseans, but Tennesseans paid more for what care they did receive.

These arguments, too, were patently false. Trump, Spicer, and others conveniently overlooked that Medicare, through its prescription drug benefit, already negotiated lower prices through private insurance companies that provided medicines to enrollees; in addition, the ACA already permitted insurance companies to compete across state lines. More broadly, the claims flew directly in the face of our data. Gutting Medicaid would surely decrease taxes for corporations and wealthy people. But those savings would come at potentially devastating costs to less affluent individuals and families living in expansion states such as Kentucky.

More importantly, research studies consistently showed Medicaid to be a cost-effective program for lower-income persons because it provided financial protections, increased rates of preventive screenings, and improved health. One 2015 study, plainly titled “Considering Whether Medicaid Is Worth the Cost,” found that the benefit of providing Medicaid was “$62,000 per quality-adjusted life-year (QALY) gained” and that states that invested in Medicaid and its expansions saw an average net return of $68,000 per enrollee.21

Researchers estimate that over 60 percent of people who file for bankruptcy in the United States do so because they are unable to pay for medical costs due to a lack of health insurance or so-called underinsurance (insurance not sufficient to cover the costs of a major health incident).

Notably, research consistently showed that medical debt disproportionally affected persons with less than a college education and households that earn less than $50,000 per year—

The logic is straightforward: less insurance correlates with poorer health; poorer health correlates with fewer productive work years and more time off work due to illness or injuries.

But this logic completely overlooked that individual actions and health behaviors of white men might raise premiums for minority populations as well. Recognizing cost as such would have meant seeing the economy of health as a larger grid, or an inescapable net in which one person pulled and another person, many webbings away, moved.

This was because, in our focus groups at least, cost connected everyone. Cost was an economy in which the well-being of white men always depended on the responsible actions of everyone else, including Mexicans and welfare queens.

A principal’s job used to be to provide vision. But now so much of what I do is shift money around. I take from here and put it there. Then I take from there and try to fill a gap somewhere else. Someday… this is going to catch up with us.… Probably already has.”

Perhaps this nostalgia arises because many Kansas narratives are penned by Odysseus-style expatriates who, much like Dorothy, gain an appreciation for home through adventures in faraway lands.

Nostalgia very often arises from false memory. What we see as homesickness or a desire to return to the old ways represents a state that psychologists might deem a post-childhood longing for an idealized time when things felt coherent; a time that may or may not ever have existed.

“They are stealing money from everywhere they can,” a retired postal worker from Prairie Village told me. “From kids. From our pensions. From our health care. From things we need. It’s ridiculous.” “I don’t know where the money is going,” said an engineer from Kansas City, Kansas. “They said businesses would flock to Kansas, but clearly that hasn’t happened. They said that more money in rich people’s pockets would flow down—but those people are just keeping it and we are getting screwed.”

The Becca Campbell story seemed important because it highlighted a central point of this book—namely, that the mortal risks of whiteness extend beyond questions of whether or not any one person holds any one set of biases or beliefs. Risk evolves from politics or policies that surround identities and give shape to interactions among people and communities.

I say this in large part because Campbell’s death became a kind of Rorschach test in which different people interpreted her intentions and actions in politically distinct ways.

The history of Missouri cities shows how liberal desegregation efforts can lead to worsening economic and racial segregation. More broadly, anthropologist Adam D. Kiš, in a book titled The Development Trap: How Big Thinking Fails the Poor, explains how grand attempts by organizations such as the World Bank to eradicate poverty can end up making life all the worse for people at the lower ends of the economic spectrum.16

Yet liberal initiatives in the United States often fail because they try to do too much at once, such as trying to provide health care or education for wide swaths of the population, without addressing the underlying social or economic systems that produce poor health or low educational attainment in the first place. Liberals also frequently fail to explain adequately the every day benefits of their initiatives for everyday people in ways that resonate or that address historically based tensions or concerns.17

It does not have to be this way. We know from American history that our communal, electoral power allows us to build vibrant social networks, safer communities, and better education systems—when we decide to do so. If impoverished structures lead to negative outcomes, then a renewed focus on restoring equitable structures and infrastructures will improve individual and communal health. In obvious and counterintuitive ways, fixing the electoral and economic structures that sustain structural racism and oppression will then better life, not just for racial and ethnic minority communities who are the objects of oppression, but, indeed, for everyone.

LeEtta Felter, the Olathe school board representative, detailed how becoming involved in politics changed her deepest understandings of race and equity. “I was raised middle-of-the-road evangelistic Christian,” she explained. “We love the Lord and believe he’s in the fiber of our being.” Yet as she toured her district and met people, her understandings of compassion evolved: When you are naive, you don’t understand that there is a chronic disparity in the system, a chronic disparity that, specifically with education, impacts achievement gaps. All of us don’t have the level playing ground that just a middle-of-the-road, middle-class white student has. It’s not just about race, it’s context of any of these indicators that put a child at risk. I have learned so much more about it that, it’s not just one or two kids, in Olathe, that’s 28 percent of our children. Those social inequities make a more complicated student coming to us, and it’s our responsibility to make sure that we invest in them at all levels so that their education that is afforded to them gets rooted, they learn how to learn, they are lifelong learners, they’re contributing to society, and the state is not just a pipeline to prison.

She describes slowly waking up to a “shaming realization… that the stereotypes I held about gun violence being an inner-city problem were simply untrue and that I was going to need to examine my own privilege and that of my own community if I wanted to make any dent in this issue.” Ultimately, “it dawned on me, and now seems so obvious, that white politicians were the ones pushing for all the guns, and gun violence was a societal issue that reflected mainstream white values and problems too.”

Similarly, efforts to incorporate immigrants into communities or promote trust across racial or ethnic lines become ever-more difficult when politicians repeatedly cast immigrants as threats to working-class white interests, African Americans as thugs or criminals, or even football players who kneel for justice as American traitors.

Increasingly, though, forces from above play to white Americans’ worst demons to assure that they don’t trust or work with others. In the absence of such collaboration, large sections of white America then come to identify these larger forces (NRA, Tea Party, Trump) as ones that keep them safe, powerful, and better off than people of other racial or ethnic groups.

What follows, as this book has shown, is the promise of greatness, coupled with a biology of demise.

demand accountability and self-reflection. In the aftermath of horrific mass shootings, including ones in his own state, Kentucky governor Matt Bevin took to claiming that laws and governments were no match for “evil”—overlooking the ways that this particular form of evil amassed arsenals under the protection of gun laws that conservatives like Bevin created or supported.

Leaders who offer zero solutions for the problems their own policies help create undermine core assumptions behind Jefferson’s notion of good governance: that government serves people rather than dividing them or making them sick.

As but one example, pro-gun politicians and the NRA go into overdrive after mass shootings in order to fault “mental illness” as the culprit while shifting focus away from guns or gun policies. The approach probably works: a national survey taken in May 2018 after a succession of school shootings at Parkland High School in Florida and Santa Fe High School in Texas found that Americans were more than twice as likely to blame “illegal gun dealers” and “mental illness” than politicians, policies, or the NRA for mass shootings.28

Meanwhile, mental illness is rarely the main causal factor in mass shootings—people who are the most severely disordered lack the capacity to plan complex crimes or are already barred from obtaining firearms.29

Threat then emerges not from shady gun dealers, insane persons, immigrants, or protesters but from the far more existential threats to well-being posed by the king, the queen, the prince, the subjects, and perhaps most important, from the royal self. This stronghold of rights and privileges thereby crafts the ellipsis of its own undoing. And the threats to life then rise, invisibly, when white America is otherwise protected by laws and policies, loaded handguns, and, in the case of Becca Campbell, the security locks and safety bags of a Toyota Highlander.