03/29/2014 12:30 am ET Updated May 28, 2014

Exploring Southern States' Opposition to Obamacare

  • How do Southern states compare with non-Southern states in their response to the Affordable Care Act?
  • What elements of the decision-making environment help us understand this region's active opposition to Obamacare?

The passage of the Patient Protection and Affordable Care Act (referenced here as ACA or Obamacare) in 2010 has elicited heated debate and resistance legal throughout the country. A slight majority of the states have taken steps against the implementation of the law -- filing lawsuits challenging the ACA, adopting statutes against the plan, or declining to accept the increased Medicaid funding provided in the legislation. Only 21 states have begun compliance with the ACA.

The muddled controversy defies simple characterization or easy explanation. However, some of my political science colleagues have begun sorting things out for the rest of us; and they presented their analysis of the situation at the recent Citadel Symposium on Southern Politics in Charleston, SC.

Their research attempted to answer the two questions posed above about regional opposition to Obamacare.

I'll try to convey their findings in this discussion. First, however, I'll introduce them: Rick Travis (Mississippi State University), David A. Breaux (University of Louisiana-Lafayette), and John C. Morris, Martin Mayer and Robert Kenter (all three from Old Dominion University).

Degrees of Support and Opposition

Whereas most of the available reporting on this topic has comprised a mixed-bag focusing on individualized lawsuits or acceptance of Medicaid expansion, my colleagues attempted to devise a comprehensive model combining five different state actions.

They divided all 50 states into categories by whether the state has (1) enacted legislation requiring health care market reforms; (2) created a health care insurance exchange; (3) accepted increased federal funding for Medicaid; (4) filed/joined a lawsuit challenging the program; or (5) adopted legislation in opposition to the ACA. By their calculations, 14 states were clearly on the "positive" side of the fight (having taken actions in favor of the program) and 21 states were clearly on the "negative" side (having taken actions in opposition to the program) of that struggle.

Southern Opposition

Their chart shows that there is no question about the regional opposition to Obamacare. Seven of the Old Confederacy states are in the most "negative" category; three additional Southern states accompany them in relative opposition; and only Arkansas finds itself on the "plus" side. This is obviously a "red-versus-blue" contest, with New York and California anchoring the blue base of support.

Explanatory Factors?

Just what accounts for the regional opposition to the ACA? The authors identified six independent variables -- party control of governor, party control of legislature, citizen ideology, poverty level, percent uninsured and public health. They found that partisan governors, partisan legislators and citizen ideology were related to state decisions to support or oppose the ACA; however, the socio-economic variables (poverty, uninsured citizens and state of public health) were not consistently related to support or opposition.


I will paraphrase my colleagues' major conclusions as follows:

  1. Their findings support the notion of Southern distinctiveness. Taken as a whole, their research showed a different decision-making environment in the South -- i.e., Southern states are driven more by politics (governors, legislatures and citizen ideology), while non-Southern states seem to be driven more by state circumstances (e.g., poverty level, health condition, etc.)
  2. Their findings also indicate that the party identification of an activist governor may be critical in shaping a state's reaction to the Affordable Care Act. If a Republican governor really wants to oppose Obamacare, then that state executive may be able to press the legislature to block implementation. Conversely, a favorably-inclined Democratic governor cannot push a state into acceptance of Obamacare, but such a leader can mitigate strong opposition to the program.
  3. They also conclude that other explanations merit further research, such as Tea Party influence and the role of race. Anecdotal evidence leads them to speculate that the former variable "might prove important"; and their instincts suggest that the latter factor "is also important."


These experts in Southern politics have produced an interesting and timely analysis as we try to keep track of the implementation of the Affordable Care Act. Their analytical conceptualization and comparative research show that something different is going on -- with an interesting mixture of political players and socio-economic conditions -- in the Southern states.

Overall, this model and analysis of such an important policy debate is a huge step in the right direction for South-watchers and national analysts. Certainly, my colleagues have provided a useful guide as Obamacare proceeds to its eventual outcome.

AUTHOR NOTE: This column is part of a series of posts about Southern politics. These posts derive from the 2014 Citadel Symposium on Southern Politics, a gathering of regional specialists in historic Charleston, SC. This Symposium has been held every other year since 1978; and it has become a main event for serious South-watchers from around the country. A hundred specialists -- representing scholars from about 50 academic institutions -- participated in the most recent conference, March 6-7, 2014. In this series, I will attempt to incorporate pertinent aspects of the presented papers and some of my own comments into various themes.