A group of activists rally against the GOP health-care plan outside on July 5th, 2017, in New York City. (Photo: Drew Angerer/Getty Images)

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.

Jamila Michener. (Photo: Cornell University)

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, being a Medicaid beneficiary makes it less likely that you will engage in various forms of politics, from voting and participating in a political group or meeting, to a wider range of ways of thinking about interacting with and engaging with government.

How does this effect play out?

When I talked to people about their experiences, they have deep gratitude for Medicaid. A lot of times the initial reaction is: "Medicaid's great, Medicaid saved my life, I would be dead without Medicaid, my child would be dead without Medicaid."

But almost invariably, once I started delving into details—what it's like to utilize these services, what the process of enrolling looks like, the benefits you do and do not get—a host of different challenges emerged. Enrolling was challenging, the bureaucratic challenges you encountered during enrollment were difficult.

People are learning lessons in those bureaucratic encounters. Most people aren't encountering the government in any significant way in their life; this is one significant way people are coming into contact with the government. When that's negative, it teaches you something about the government, and it teaches you something about your place in relation to the government.

In addition to that, there's just a question of resources. People realize when, for example, the resources that Medicaid has to offer are insufficient—when they're not able to get dental coverage even though their teeth are affecting their health more broadly. Or they're not able to get vision coverage and have their glasses paid for. Or even when we have expansions and retractions of the program. When people at some point have a benefit, and then it's taken away—that really stands out to them. It makes the limits of the government very clear: I have this thing I really need, but obviously the government is not able to provide for it. It also makes the capriciousness of the government really clear: I once had this thing, but I don't know if I'll be able to have it next year because we get things and we get them taken away.

How do these state-level program differences that you mentioned before affect political participation? What makes people more or less likely to participate?

On the state level, there are policy choices states can make that shape whether Medicaid is disempowering. One of the things people would say to me when I first started getting this finding about Medicaid having a negative relationship to political participation was: "Well, conservatives are going to love this because they can say that these welfare programs are bad for democracy. It just provides them with more of a reason to cut."

That is a disingenuous interpretation of the finding. The argument isn't just that these programs, inherently or invariably, are going to disempower people. We're not disempowering people because we're giving them free stuff and making them lethargic and apathetic. That is not the mechanism. The mechanism is when we design policy that is capricious, or that is ungenerous, or that is administratively burdensome, it contributes to experiences that alienate people from government and politics. It's about the way the program is designed, administered, and ultimately implemented.

That also means it doesn't have to be this way. When we're taking things away from people, that sends them a signal that causes them to disengage; expansions do the exact opposite. In places where Medicaid has expanded, we actually in the period immediately thereafter see boosts in rates of voting. There have now been a few studies that have identified this effect.

Obviously, a lot of the changes to Medicaid we're seeing under the Trump administration—in the form of state-level waivers around work requirements, for example—move the program in a more burdensome direction.

Federalism is not going anywhere. But we don't think enough about the consequences of that system and that structure for inequality, both material—differences in the resources different Americans have access to for no reason other than their place of residence—and political inequality. That should concern anyone who cares about democracy.

Those material inequalities lead to disparities in political engagement, and the kinds of disparities that emerge reinforce pre-existing inequality. For example, if we look at the states that haven't expanded Medicaid, those are states that disproportionately hold relatively large numbers of African Americans and people who are living in poverty. Those are the places where Medicaid is likely to have a negative relationship to political participation because they're not expanding, and there are various forms of retrenchment and various kinds of punitive changes that are happening in those states with these waivers. And the beneficiary populations in these states are people of color and people who are living in poverty.

A work requirement introduces all this additional labor where Medicaid workers have to essentially make sure you're out looking for a job. And if you think about the capriciousness—if you don't have your hours this month, you're kicked off, and then if you get your hours again, you're back on—that kind of back and forth is exactly the kind of thing that causes people to disengage from government. Because who wants anything to do with a government that is treating your life so blithely? It does not bode well for incorporating these kinds of folks into the political system.

This interview has been edited for length and clarity.