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

by Jonathan M. Metzl

Historian Michael Ralph describes Civil War–era slave insurance as central to the formation of US health and life insurance industries and a way that owners of capital sought to shield themselves against the risks associated with the loss of an individual’s capacity for labor: The same period which witnessed the demise of formal enslavement saw the debut of structures that protected the privilege of people whose wealth and power suddenly threatened to come undone: this would include sharecropping and convict leasing.5 Thus, topics of health care and health insurance in Tennessee were already imbued with historical tensions long before the ACA, as questions such as Whose life is worth saving and insuring? or Whose bodies are seen as risky? coursed through larger debates.

According to Tesler, the ACA expanded an already deep divide between black and white Americans’ support for government programs, whereby African Americans became “overwhelmingly” supportive of the ACA while white Americans increasingly believed that “health care should be voluntarily left up to individuals” rather than the federal government.

On the whole, many Southern men embody what historian C. Vann Woodward once called the “divided mind” of the South, in which Southerners, and Southern white men in particular, seek the material gains of modern America while still holding fast to mores, prejudices, or historical traumas of their regional pasts.

Many men interpreted cultural and public health messages through powerful frameworks of individualism and personal choice.

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.

accusations of socialism and communism functioned as central components of conservative critiques of health care reform.

Again and again, mentions of government, ACA, health care expansion, or system reform elicited white male anxieties about the usurpation of health and economic resources by irresponsible, lazy, and often racialized others.

Answers to seemingly straightforward questions about health behaviors and attitudes revealed a group psychology that identified health risks on welfare mothers, Mexicans, gangs, and other abject others who undermined the system. 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.

Behind concerns about people on welfare using it up and mothertrucking Mexican immigrants draining Medicaid (even though undocumented immigrants did not qualify for the program in the first place) lay anxieties about limited funds, support services, and other essential commodities for which they might have to contest, should equal distribution become the law of the land.

Whiteness, to again reference historian David Roediger, became the currency through which the men laid claim to their dwindling benefits. Conversely, candidates like Donald Trump preyed on these men’s fear of losing even more of their dwindling privilege and security.

W. E. B. Du Bois once described the doubly conscious experience of black America in which internalized identity coexisted with the thousand cuts of everyday restrictions and subliminal racisms.

But black men consistently differed from white men in how they conceived of government intervention and group identity. Whereas white men jumped unthinkingly to assumptions about “them,” black men frequently answered questions about health and health systems through the language of “us.”

For these men and others with whom we spoke, questions about responsibility and health elicited responses using us, we, our, and other autobiographical monikers that connoted communal responsibility. We implied populations forged by race and ethnicity—we as African Americans—as well as by assumed common attitudes and experiences—“our family, our parents.” We, as Chicago Defender editor Robert S. Abbott once put it, implied “the Race.”2 Through this framework, black men in Tennessee generally provided profoundly different replies about government intervention into health and health care than did white men.

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.

Black men’s responses were far from monolithic. Yet on the whole, the anxiety central to the white groups—a constant pressure to bear and embody the cost of staying on top—remained absent when black men spoke. Instead, unburdened by ideologies of supremacy or the invective of fallen greatness, black men narrated health care as a benefit—rather than as what the historian Roediger called a wage.

Where white men often defined government involvement as a risk or debt, many black men saw a communal safety net as an investment. Expanded health care enabled well-being for highly practical, seemingly nonideological reasons: health care allowed more people to go to doctors and to do so before they became gravely ill, thus saving money and improving quality of life.

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. Nonpartisan groups such as the Congressional Budget Office (CBO) estimated that expansion would ultimately lead to a 2.8 percent increase in Medicaid spending for states like Tennessee from 2014 to 2022. Yet this increase paled in comparison to the net savings that state and local governments would realize in health care spending for the uninsured—up to $101 billion in uncompensated care according to leading health care consulting firms.

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. Putting their bodies on the line created categories of us versus them, defenders versus invaders. And perhaps the gain then accrued, not so much from a biomedical perspective but from what historians and theorists such as Du Bois have described as the psychological benefits of being white—or what historian George Lipsitz once termed a “possessive investment in whiteness.”

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.

all-cause mortality—essentially, the rates at which people die.

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

mortality decreased by 2.9 percent in Massachusetts and by 2.4 percent in the state’s white populations after the implementation of the comprehensive health reform known as Romneycare, a state-run health insurance program that provided the intellectual framework for the ACA.

Kentucky broke with Tennessee and most other Southern states when it embraced the ACA and expanded Medicaid. In May 2013, then governor Steve Beshear, a Democrat, announced to much fanfare and predictable resistance that the state would expand Medicaid to cover most adults with incomes under 138 percent of the federal poverty level and support insurance marketplaces as well. Beshear called the expansion “the single most important decision in our lifetime” for improving the health of Kentuckians—who traditionally ranked near the bottom of the US population in nearly every health indicator.

Kentucky posed a stark contrast to trends seen in Tennessee: 425,000 Kentuckians, representing fully 10 percent of the population, gained coverage in the first year alone—even though the Medicaid expansion did not go into effect until a year later. According to an in-depth study published in Health Affairs, the percentages of the state’s low-income adults without insurance dropped from 40.2 percent to 12.4 percent as a result of expansion—one of the largest reductions in the country.

Studies show a roughly 25 percent higher risk of death among uninsured persons when compared with privately insured adults.

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).

the context of people’s lives determine their health, and so blaming individuals for having poor health or crediting them for good health is inappropriate. Individuals are unlikely to be able to directly control many of the determinants of health.

In one example from our focus groups, white men believed that their costs rose due to the irresponsible actions of gangbangers, Mexicans, and minorities. But this logic completely overlooked that individual actions and health behaviors of white men might raise premiums for minority populations as well.

Cost, in other words, functioned as a metaphor for concerns about a system that gravely threatened the sense of individualism underpinning particular white notions of health. This point is often overlooked by progressives who reflexively argue for government health care for all without taking account of the racial and historical intonations of federal health care networks in places like Tennessee. Here, seemingly self-evident arguments about communal well-being and shared risk engender specific forms of white anxiety. 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. Debt in the context of health care suggested that, even though some owed more and some less, the health of white Americans was always and already beholden to others.

And though the ACA and Medicaid expansion would have cost real money from somewhere, the dirty little secret of federally funded health care programs in states like Tennessee is that much of the actual expense would be borne by the taxes of… Northerners.

Yet the graphs suggest that expanded marketplace options yield competition rather than price-gouging and that investing in the health of everyone ultimately lowers a variety of costs for… everyone. People go to doctors sooner rather than in times of crisis. Healthy people buy into the system. Premiums for everyone begin to decline.

Trump essentially asked lower-income white people to choose less coverage and more suffering over a system that linked them to Mexicans, welfare queens, and… to healthier, longer lives.

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.

“Why should we pay for immigrants or for educating their kids when they take our jobs and don’t even pay taxes?” was another familiar refrain—mirroring the language of increasingly vocal anti-immigrant politicians in the state.

It turned out that, contrary to hyperbolic reports of government waste, the state had frequently used tax revenue to pay for roads, bridges, traffic lights, aqueducts, conduits, and causeways—structures often supported by communal governance, and for which wealthy persons who receive tax breaks do not often clamor to invest their surplus funds.

Bloomberg News summarized: “The Kansas supply-side experiment unravels… tax cuts were supposed to spur growth, boost revenue and create jobs. The results were the exact opposite.”

And the poorest 40 percent of Kansans saw an average net tax increase. The poorest 40 percent. They saw their taxes go up as a result of this. Whereas the wealthiest 5, 10, 15 percent saw just overwhelming reductions as a result.… The wealthiest in Kansas saw [tax] reductions,

After the GOP tax bill passed in 2017, sociologist Isaac Martin penned a column in the New York Times titled “How Republicans Learned to Sell Tax Cuts for the Rich,” in which he lay the answer in good marketing, a rejection of expertise, and the corrupted populism of Andrew Mellon. Mellon found a way to convince the American masses of the faulty proposition that “cutting income tax rates would actually increase tax revenues. In particular, he said, cutting the top income tax rates would encourage rich people to pull their money out of tax shelters and invest in creating jobs.”

This leads to another tension driving American austerity politics: its connections to, and implications for, race and racism. A long literature details relationships between tax cuts, austerity, and race. In the US context, much of this work highlights how tax cuts disproportionately benefit rich white males at the expense of other groups of people in society. Tax cuts also lead to shortfalls in government services and programs that frequently assist women and minorities. Persons on government assistance, undocumented immigrants, and single mothers receiving child support are just a few of the groups who live and work in economies where income is largely fixed and thus unaffected by reduced tax rates.6

In a brilliant analysis of this phenomenon, journalist Gary Younge details a complex dynamic in which poor white populations vote for politicians who enact cuts to government spending out of a combination of anger that the government is wasting money on “people who do not deserve it,” alongside guilt that they themselves need help.

Well-off white populations may have gained a sense of privilege along with unimaginable financial gain within a rapidly changing world, but spending so much capital on a system that limited mobility and integration boomeranged for middle- and lower-income white populations, and particularly for white families who sent their kids to public schools.

Critics derisively called the tax cuts Brownback v. Boards of Education.

For an increasingly vocal cohort of Kansans, the downside of austerity hit home when it affected their children. Events on the ground began to upend the belief that the consequences of tax cuts were happening somewhere else, to someone else. “School cuts definitely started out as something that people thought were only geared toward inner-city, black, and Hispanic schools and districts,” one administrator explained. “That’s how they were sold at first.”

If you can pull yourself up by your bootstraps, please do. But these Brownback policies… I saw them hit the most when I learned about race and poverty in our state. I’ve become a little bit more broadened by my experience dealing with impoverished folks, the systemic cycle of multigeneration poverty, those living in poverty. I’ve seen, they don’t even have bootstraps to pull themselves up by. It’s quite different than what my white, middle-class upbringing led me to believe.

Eighteen thousand, five hundred fifty lost years of life after only four years of budget cuts—and using data that conservatively addressed rising dropout rates and not the larger figures of falling graduations.

In these ways, modern-day trickle-down theories seem to fail on their titular promise. Nothing trickles down. Wealth condenses, and the system repays the shareholders rather than the consumers of services.

policies that carry negative mortal consequences for everyday people are not the sole domain of any one political party or ideological persuasion.

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.

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.

the construction of whiteness as a castle under siege, and the policies that sustain it, comes with certain benefits