Fragmented Democracy: Medicaid, Federalism, and Unequal Politics

by Jamila Michener

Medicaid is the single largest public health insurer in the United States, covering upwards of 70 million Americans. Crucially, Medicaid is also an intergovernmental program that yokes poverty to the federal government determines its broad contours, while states have tremendous discretion over how Medicaid is designed and implemented. Where some locales are generous and open handed, others are tight-fisted and punitive. In Fragmented Democracy, Jamila Michener demonstrates the consequences of such disparities for democratic citizenship. Unpacking how federalism transforms Medicaid beneficiaries' interpretations of government and structures their participation in politics, the book examines American democracy from the vantage point(s) of those who are living in or near poverty, (disproportionately) Black or Latino, and reliant on a federated government for vital resources.

Genres: Politics, Nonfiction, Race, Health Care, Public Policy, Sociology, Health

236 pages, Paperback

Published March 22, 2018

Reviews

[Claire Kasinadhuni · Rating 5 out of 5]

I normally don't add books I read for class on Goodreads but this one was fantastic and enriching and important. Although federalism isn't necessarily the devil or the root cause of inequality related to Medicaid, it is an interesting framework to consider the consequences of policy fragmentation and geographical differences on social citizenship. This book convinced me (I didn't need much convincing) that we need a federally nationalized program or to force states to implement minimum standards. In the absence of this, states will continue to disenfranchise the most vulnerable groups in America with the added perk for conservatives of suppressing the vote.

[Joel · Rating 4 out of 5]

I think this was an excellently written book with solid research all around. It was shocking to see just what an impact merely interacting with the Medicare system could have on one's political participation. That being said I would have liked to see a more intersectional approach when gathering this data. For example, women of color are more likely to live in poverty, and to live in the type of disordered neighborhoods, outlined by Michener. And both of these were found to be contributing factors towards a decrease in one’s political participation. In fact in a matched sample conducted by Michener, both race and gender had a significant impact regarding political participation for Medicare beneficiaries. So we'd certainly expect to see such an effect compounded for women of color. For this doubly marginalized group, it would have been nice to understand the realities and complexities of their situation.

[Ethan · Rating 4 out of 5]

So much covered in here, but what stuck out to me was the people willing to put up with inadequate care because they themselves believed they deserved it-awful stuff.

I did like when that nurse renounced the Hippocratic oath for legislators who were trying to privatize Medicaid-real

[Kirsten · Rating 4 out of 5]

The thing I love most about this book is the inclusion of the voices of people who aren't often heard -- recipients of Medicaid. The author pays caring attention to the lived experiences of people struggling for critical medical care, while expanding how we think about federalism and its impact.

[Jared Knowles · Rating 5 out of 5]

One of the best books I've read on federalism and also one of the best books I've read about social welfare policies in the United States. A groundbreaking work.

[Rachel Lee · Rating 4 out of 5]

I found myself on a “reading rollercoaster” with this book. I’m not a political scientist by any stretch so this rollercoaster is no fault of the author. When she weaves in the stories of beneficiaries, I felt like my brain could relax and comprehend. Otherwise, I was spending so much time trying to keep up with her data collection methodology and explanations of how and why she did things; again, I think for someone studying this for a living, it would be a bit easier to follow.

I do feel that I got the gist though. Medicaid is imperfect, it’s foundation and subsequent intersections with federalism make the program convoluted, capricious and not centered on the beneficiaries. There was a great deal of research that went into this book and I appreciated the author centering the voices of those who are often in the margins.

[Alekhya Bhat · Rating 5 out of 5]

I had to read this book for an assignment for class, and it actually taught me a lot about the American healthcare system.

The examination of Medicaid as a case study within federalism illustrates how policy disparities affect political behavior and civic engagement among beneficiaries. It underscores the implications of state-specific policies on citizens' perceptions, political consciousness, and participation within the political realm. By emphasizing the multifaceted repercussions of policy alterations and the role of federalism in shaping political attitudes, the book speaks directly to contemporary discussions surrounding healthcare policies, governance, and civic engagement.

Additionally, the chapters on urban inequality and policy advocacy within a fragmented polity highlight the intersection of federalism with immediate environments and advocacy efforts. These chapters resonate with current societal challenges, emphasizing the significance of neighborhood dynamics and the complexities of policy advocacy in a federated political system.
Michener’s book speaks directly to the pressing issues in contemporary American politics, offering insights into the complexities of federalism, policy disparities, and their democratic implications. It provides a nuanced understanding of how variations in policy provisions significantly impact political engagement and citizenship, making it highly relevant to ongoing debates and policy considerations in today’s political landscape.

The research conducted in “Fragmented Democracy: Medicaid, Federalism, and Unequal Politics” by Jamila D. Michener aims to scrutinize the disparities within Medicaid across different states and their implications for democratic citizenship. The overarching research question revolves around understanding how Medicaid, as a federal-state program, affects political engagement, citizenship, and democratic participation among its beneficiaries, especially considering the geographic variations in Medicaid provisions.

Michener adopts a multi-dimensional approach to investigate this question. The evidence base includes varied experiences narrated in the book, incorporating individual stories like Terrie, John, Fiona, and Daphne, highlighting the disparities in Medicaid provisions and the resultant challenges faced by beneficiaries across states, counties, and neighborhoods. For instance, Terrie's narrative emphasizes the impact of interstate travel limitations and state-specific regulations on health and productivity, whereas John’s dilemma underscores how Medicaid ties individuals to specific states, limiting mobility and healthcare access. These narratives, along with others, illustrate the intersection of Medicaid with local socio-economic dynamics, revealing its profound influence on political lives and citizenship.

This book offers a comprehensive analysis of Medicaid’s impact on democratic citizenship. Its findings underscore the enduring significance of federalism in shaping political engagement and citizenship experiences, paving the way for future research to explore similar dynamics across various groups and policy domains within American politics. Fragmented Democracy characterizes Medicaid as a crucial aspect within the framework of federalism, accounting for its intricate design that leads to policy fragmentation across states and local levels. It's highlighted as the largest public health insurance source in the US, primarily providing coverage for low-income Americans. Michener reiterates the program's significance — its direct impact on the most marginalized citizens, overwhelmingly benefiting the poor, including people of color and those prone to health issues.

By delving into how federalism molds Medicaid, Michener explores political involvement for recipients. Her analysis uncovers state disparities, emphasizing federalism's role in democratic inclusion. Prioritizing Medicaid beneficiaries’ experiences, Michener urges a deeper grasp of federalism's impact on political agency. Aligned with scholarly discussions, her work highlights representational complexities and policy diffusion. It stands as a crucial resource, urging advocates to address political inequality and foster fair democratic engagement within the American federal system.

[Jamie from The Doer Co · Rating 5 out of 5]

Very much enjoyed seeing Jamila speak and discussing her ideas in person. For anyone interested in the efficacy of Medicare across states, this is an incredibly thorough collection and synthesis of the major, cross-discliplinary literature about it. I personally don't agree with her major assertions about solutions, but her hypotheses surrounding recipient behavior and outcomes on Medicaid are very interesting. It's packed with data but is still very readable. You don't need to understand how to read any graphs and figures presented in the book due to her clear, narrative writing style. I especially appreciate what her proprietary qualitative research adds to this conversation.

[Daniel · Rating 5 out of 5]

This is a most important contribution to the literature on Medicaid and, indeed, American social programs generally. Combining comprehensive (and a times quite touching) interviews of beneficiaries with rigorous quantitative analysis, Michener shows how the ways individuals 'dialogue' with this important government program impacts their overall level of political empowerment.

[Diana Marie Denza · Rating 5 out of 5]

A well-written, fascinating account of how federalism disadvantages large swaths of the population who rely on Medicaid. It centers the voices of people on Medicaid, who rarely enjoy that level of attention.

[A'Llyn Ettien · Rating 3 out of 5]

Very interesting exploration of the history, present, politics and users of Medicaid.

[Jackie · Rating 5 out of 5]

This is the kind of Political Science I want to be doing. Centering the experiences of people who are living this dystopia. Thank you for leading the way.

[Melissa · Rating 4 out of 5]

This book was fascinating!!

[carla · Rating 4 out of 5]

also read for my social policy class but much more interesting since it introduces policy feedback theory and how the failure of welfare policy fragments trust in government!