The United States spent approximately $553 billion in 2016 on Medicaid, making it the third-costliest program in the federal budget (behind Social Security and Medicare).
Medicaid covers 76 percent of low-income children, 48 percent of children with special health-care needs, 45 percent of disabled adults, and over 60 percent of nursing home residents. Thirty-one percent of African Americans and 33 percent of Hispanic Americans are covered through Medicaid. In some states—Arkansas and Louisiana, for example—the program covers as much as two-thirds of all births.
In years past, researchers have studied the effects of Medicaid on everything from health, to the labor market, to educational outlook. In her new book, Fragmented Democracy: Medicaid, Federalism, and Unequal Politics, Cornell University political scientist Jamila Michener explores Medicaid’s effects on another crucial variable: political participation.
Michener sat down with Pacific Standard to talk about her new book, how state-level decisions around the program can politically empower or disempower beneficiaries, and what the waivers granted by the Trump administration mean for the political engagement of the most marginalized Americans.
How does Medicaid vary across states?
Everything from the name of the program—and therefore how people are conceptualizing it—down to what you can get as an enrollee of is really, really different. As I went from location to location [for the book], I realized there were people in specific states who were enrolled in Medicaid and didn’t really realize it was Medicaid; they thought of it as whatever the name of the state program was—PeachCare in Georgia, for example.
But when you start talking to real people, they were [still] aware of those differences. People would say things to me like, “Well, in Georgia, you can get full coverage for dental, but you’re only gonna get partial coverage for vision. And you can only get three physical therapy sessions a month, and Medicaid will only pay for one pair of glasses—and then only if I get my optometrist to say that I’m very close to being legally blind.” There were all of these nooks and crannies of details about what would and would not be covered, and beneficiaries were very aware of that.
Why might we expect Medicaid recipients to display different patterns of political participation?
In political science, we call this “policy feedback”: the idea that policy affects politics. What people get from the government, and how they experience getting whatever it is they get—or, alternatively, what they don’t get, or what burdens are imposed on them from the government—all affects the way people understand government and politics, and their place in it. It affects whether they engage and participate in political activity.
These policy feedback effects vary from program to program, right?
Right, and, going into this research, it wasn’t entirely clear to me where Medicaid would fall. Because there’s policy feedback literature that looks at programs like Social Security or GI benefits. Those are generally universal benefits that a lot of people have positive experiences with and boost the likelihood of engaging in politics. That’s an example of positive feedback.
Then political scientists look at feedback effects for more typical welfare programs like cash assistance, and find the opposite: that those programs can really depress your political participation and make it less likely that you engage.
What I find in the book is that, at least on average, we do see the negative feedback. When I compare beneficiaries to non-beneficiaries,…