Health Equity and Democracy

Wednesday, July 11th, 2018

Follow this link to watch Jamila Michener’s presentation on YouTube.

This past month, we partnered with Cornell in Buffalo to bring Dr. Jamila Michener to the TR Site for our ongoing Speaker Nite series. Dr. Michener is an Assistant professor in the department of Government at Cornell University and author of Fragmented Democracy: Medicaid, Federalism and Unequal Politics. Her presentation, “Health Equity and Democracy” explored the way experiences with Medicaid influence the way beneficiaries perceive and interact with the government.

Dr. Michener began her talk by explaining the process that led her to this topic. While tackling Medicaid was not her original intention, after interviewing people across the country about issues that mattered to them and how the government intersected with those issues, it became clear that health care was a dominant theme. As she began to explore the topic further, a broad story emerged about how people were experiencing Medicaid. Approximately 90% of non-elderly Medicaid beneficiaries live at or below the poverty line. With so much of the Medicaid experience being directly linked to experiences with poverty, Dr. Michener began to look at how those issues impact the way people experience citizenship. She defined (democratic) citizenship as being a part of the social and political community. Specifically, the idea of having political rights (the rights that allow you to have voice) and social rights (the rights that allow your very basic needs to be met). During the course of her research, many people brought up Medicaid when asked about the government’s role in their lives, suggesting to Dr. Michener that their democratic citizenship was influenced by their participation in the program.

Part of the broad story she discovered were shared experiences. Many of the people she spoke to brought up the stigma associated with Medicaid. Whether it was feeling embarrassed or seeing the way other people view Medicaid beneficiaries, recipients repeatedly brought up the negative emotions they experienced. Their feelings were often exacerbated by the negative interactions they had with the Medicaid bureaucracy. One story stood out in particular: a nurse from a solidly middle-class background was forced to apply for Medicaid after the birth of her fourth child. Her child was born with a severe disability that required close to 2 million dollars’ worth of medical care per year just to keep him alive. The family’s private insurance would not cover all of their needs and she was forced to apply for Medicaid. Despite her experience as a nurse and as the head of a clinic, she described the complexity of the application process and the difficulty she experienced when trying to enroll in the program. If someone working in the medical industry couldn’t make sense of the application, how is a person living in poverty going to access the benefits they need?

In an attempt to address that and many other questions, Dr. Michener began looking at the quantitative data to see if these experiences had a tangible impact on political engagement. After conducting a staggering number of interviews, Dr. Michener developed a hypothesis.   Having identified Medicaid as one of the most significant intersections of people's lives and government programs, and further realizing that those experiences elicited strong negative emotions, she suspected that this group’s political participation would be lower than a group of individuals not on Medicaid. Interestingly, after compiling the initial data, that’s exactly what the numbers showed. However, Dr. Michener pointed out that the easiest and most obvious answer is not always correct. So, she re-evaluated the data set, controlling for a myriad of factors that could also be contributing to the relationship. Remarkably, no matter what she controlled for (and the list was exhaustive) the relationship between Medicaid participation and reduced political participation remained.

That raises a very important question: if Medicaid participation is discouraging political participation, does that make Medicaid bad for democracy? No! Well, that’s the short answer according to Dr. Michener, who sought to explain the connection in a more nuanced way. After speaking to a woman who had moved frequently while on Medicaid, the differences in the way each state implemented the program became clear. While Medicaid is an intergovernmental program that’s funded by both the federal government and the state, states make individual decisions that can address the gaps in the broad framework proscribed by the federal government. Those differences have a tremendous impact on how people experience the program. Some states offer better plans that cover more, while others have less coverage with an easier application. In some cases, the differences between states are so extreme that the coverage offered in one state is not be recognized in another, even though Medicaid is a federal program.

At this point Dr. Michener took a step back to speak about people’s feelings about Medicaid. Overwhelmingly, the people she interviewed expressed their appreciation for the program and spoke highly of their doctors. A number of the people she spoke to said they would not be alive if it weren’t for Medicaid. It was clear to Dr. Michener that this was not an issue of people being unsatisfied and demanding more and more and more from the government. Instead, she asserts that it’s about the experience of seeking these lifesaving benefits and how demeaning, frustrating, and disempowering the process is. Quite simply, beneficiaries felt like no one cared about them and that they were not in a position to advocate for themselves.

Compounding that point further are the frequent changes in coverage. What was covered one year may no longer be covered the next. Dr. Michener told the story of a woman who went to her OB/GYN for a Pap test only to be told it was no longer covered by her insurance. The woman was left reeling and asking, “Isn’t my health still important? Does it still matter whether or not I have ovarian cancer? Isn’t this vital to my life?” This kind of capricious coverage sends a strong message to Medicaid recipients. Beneficiaries are left wondering if they or their peers are valued at all by policy-makers. When people are left feeling like just another number, they recognize that and respond by disengaging with the system.

One of the last points Dr. Michener made was about the beneficiaries themselves. When politicians argue over Medicaid, all sorts of claims are hurled at recipients who are “cheating the system” or are “living off of the government”. Dr. Michener pointed out that: (1) there are so few cases of people living entirely off the government that it really should be considered a moot point; and (2) beneficiaries are savvy. Perhaps they should be recognized as doing the best they can to navigate a broken system that inherently discourages upward economic mobility.

Dr. Michener finished her presentation by looking at the most recent changes to health care policy and the future of Medicaid. She made a compelling case for how her research might be used to inform change.

Thank you to Alessandro Powell for the photo of Dr. Michener speaking with audience members.

- Lindsey Evans, Public Programming Assistant

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Speaker Nite is part of the TR Site’s regular Tuesday evening programming, which is made possible with generous support from M&T Bank, as well as the New York State Council on the Arts (NYSCA), with the support of Governor Andrew Cuomo and the New York State Legislature.

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