Living in a fragmented democracy

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At the end of March, millions of Americans lost access to Medicaid as pandemic-era expansions to the program were rolled back. At the same time, North Carolina’s legislature voted to expand Medicaid, marking a demonstration of bipartisan agreement in these polarizing times. This backdrop makes it a very interesting time to talk with Jamila Michener, who studies both the specific politics of Medicaid and how the political fights over Medicaid illustrate larger issues in federalism and democracy.

In this episode, we discuss how receiving government benefits like Medicaid impacts political agency, whether it’s possible to square federalism and equality, and more.

Michener is associate professor of government at Cornell University and author of Fragmented Democracy: Medicaid, Federalism, and Unequal Politics. In the book, Michener 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.

Fragmented Democracy: Medicaid, Federalism, and Unequal Politics

Michener on Twitter

Episode Transcript

Chris Beem
From the McCourtney Institute for Democracy at Penn State University, I’m Chris Beem.

Candis Watts Smith 
I’m Candis Watts Smith.

Jenna Spinelle
I’m Jenna Spinelle, and welcome to Democracy Works. Our guest this week is Jamila Michener, who is an associate professor of government at Cornell University, and author of the book Fragmented Democracy: Medicaid, Federalism and Unequal Politics. This book has been out for several years now. And but I really think that some of the things that we’re seeing happen right now, with the rollback of some of the pandemic era expansions to public assistance, broadly defined, whether that’s housing assistance, or food assistance, or things like Medicaid, Jamila and I talk about that in the interview, but I think this is a really important time to be thinking about how the distribution of these benefits this assistance, it has impacts on federalism and equality and our democracy more broadly.

Candis Watts Smith 
On March 31, the U.S. government will essentially kind of do a wind down around Medicaid. And I’m not really sure if a lot of people are aware of that. And I think it’s really, I guess, on some level, it’s really good to have Jamila, here, right now, as a scholar of race, of poverty of policy, she makes salient millions of people who are otherwise made invisible to most people, her twitter handle is poverty scholar. And I just, I really admire Jamila, as an academic, her work is really careful. And it’s often beautifully written. But also she does the work of turning common sense on its head, and really asked us to think about the assumptions we make around poverty and poor people. So for example, I think the fact that there’s not a huge headline about the unwinding of the COVID-19, related Medicaid, unwinding tells us that the media is not necessarily speaking from the perspective of people in poverty. So her work kind of asks us to think about, you know, under what conditions, are we really seriously considering the well being of poor folks? And what does it mean that we may or may not care about a large and sometimes growing group of people, for the health of our democracy.

Chris Beem
It is striking that there isn’t more news around this event. I mean, you know, COVID, is no longer emergent, you know, whatever its status and, and so it’s that, you know, some of the expansion of Medicaid, it happened around that much of the expansion, but we’re still talking about, you know, somewhere around between 80 and 90 million Americans, which is just a staggeringly high number. And the idea that that this is going to go away, is going to have significant impacts with regards to health care with regards to health outcomes with regards to what happens to rural hospitals, what happens to, you know, hospitals in urban settings, where they’re suddenly overwhelmed, going back to emergency rooms serving as points of care or entree into the healthcare system. I mean, we don’t really know. And, you know, you hear these wide estimates about how many people are going to go back to being uninsured between what is it between 4 million and 15 million, something like that. But it is a big event. And it’s a big event for an enormous number of Americans. And there are no Americans who won’t feel the impact of this.

Candis Watts Smith 
So, you know, we expanded Medicaid enrollment and then allow continuous enrollment, because there was a recognition that people needed health care during the pandemic, is that not the same when we do not have a pandemic? So, you know, one of the things I think that Jimmy does work highlights is that policy Telegraph’s messages to the public about who is deserving and who is undeserving, who should be cared for and who shouldn’t, who should be able to live with dignity, who should be able to participate in politics. And so, you know, there’s oftentimes you talk about, you know, low income people and people facing poverty don’t participate. Well. What kind of signal are we giving to people to say, we actually do not care if you are or are not insured? And you know, just to kind of be more nuanced about it is that because Medicaid And we can talk more about this later because Medicaid is partially allocated with state funds, that some states have a higher tolerance for inequality than others, some states have a higher tolerance for on democratic institutions than others. But you know, here, I think that all of this helps us to kind of see that our policies tell us something about our own values about who we value, what we value and the extent to which we’re willing to make sure that people have what they need. So, you know, I’m so appreciative of Jamila, kind of bringing up this conversation about Medicaid, because on one level, it seems so niche, I mean, you know, like, aside from the fact that 80 million people, yeah, that’s a pretty big niche. But like, policy wise, right, it’s not really a policy that people think about a lot. But when we start using it as a case, we can see the things that it highlights about poverty, about inequality, about federalism, about racism, mercy, about racism, about representation, all of these things are really illuminated, when we start unpacking how Medicaid works and doesn’t work for Americans.

Chris Beem
Well, and when you I mean, with respect to Medicaid, you know, you have exhibit A, and then Medicare as Exhibit C, you know, and so you can see, in stark contrast, how these programs that are ostensibly are meeting the same need are just understood and treated. So incredibly, definitely.

Jenna Spinelle
Yeah. And I think we do definitely talk about that, in the interview, the difference between Medicare and Medicaid politically, and how that impacts the way that recipients of those programs view themselves and their sense of political agency. That’s a word that comes up a lot. So thank you both for setting the table there for us. And let’s go now to the interview.

Jamila Michener, welcome to Democracy Works. Thanks for joining us today.

Jamila Michener
Thanks for having me.

Jenna Spinelle
So, you know, as I was reading through your book, fragmented democracy, I wrote in my notes that on the one hand, it’s about one very specific policy program, that’s Medicaid, but it’s also in some way, it’s about everything about all of the ways that it’s a much bigger conversation about equality and policy and democracy. And so I guess I wonder to kick us off here, you know, how you kept those two thoughts in your head at the same time, as you were working on the book, and in the work you’ve done after, you know, focusing on this very narrow policy on the one hand, but also zooming out and thinking about and telling this much bigger story?

Jamila Michener
Yeah, that’s a great question. I love that you can see both of these at the same time, when you look at the work. Honestly, I started in a more focused place, which was, because so much of the book was grounded initially, in what I learned from people, when I talk to them in a way that brings you like very much to the micro, you know, like you’re talking to people about their experiences. And so you are thinking about a specific program, specific people, how they understand it, how it affects their lives. And for me, that kept it really interesting, because it wasn’t just some abstract theoretical concept. It was very real in very many people’s lives, you know, even more people now than when I wrote the book, right? What is upwards of 80 million people on Medicaid at this point. And so it’s, in one way, I thought, I’m gonna write a book about one policy, that policy might as well be one that like 10s of millions of people rely on because it might be one policy, but it has a really big imprint in people’s lives. But then as I talk to people, I realized this wasn’t just about one policy, it was about the structure of our political system and the structure of our political lives, right. And so I didn’t start off thinking, I think, if I started off thinking, I’m going to write a book about federalism and political equality and political institutions, and I probably would have been overwhelmed, honestly. But instead, I started off thinking, I want to understand this program, which is huge and important, and what it means in people’s lives, and specifically what it means for democracy. And then I kind of panned out, as I learned, and it ended up being about these bigger things. But that was a process that happened slowly so I was able to ease my way into it and not be like too overwhelmed.

Jenna Spinelle
And I want to come back to some of the other ways that the inequality that you describe is playing out across other policies, but can you talk a little bit about the history of Medicaid was the inequality that you discovered kind of baked into it from the start, or did it evolve over time as the program expanded?

Jamila Michener
Yeah, I love that, you know, the answer is both it was baked in from the start. And then it evolves continually over time. I mean, Medicaid, although it’s huge now. And it’s a lot of kind of state budgetary footprints, even the federal budget. It started off, understood to be a program or designed to be a program that was going to be pretty small, right? Like all the action was in Medicare, people who were over 65 elderly people were very much understood at that point, when Medicaid first kind of came into being in the 1960s, the people who are understood to be the most in need, and also the most like, politically powerful, who really needed to be responded to on a policy level where like elderly people who had very few options when it came to health insurance and very great needs. And so a lot of the focus at that time when the legislation was being developed, was on Medicare, right, understandably, so. And so Medicare was designed in a way that reflected the fact that policymakers really wanted to serve this over 65 constituency, it was universal, anyone over 65 can get it. It was centrally administered. It’s not like what state you live in changes what kind of Medicare you get Medicare is Medicare, no matter where you live, it was a social insurance program imagined as something that people would pay into and then be able to rely on when they got to be older. It was all the things that we often really like about the way social policy is designed. And it was for a pretty sympathetic group of people like elderly people, you know, who have worked hard their whole lives, Medicaid was kind of tacked on, because it was like, oh, maybe we should do something for poor people, too, right. But it didn’t have the political sway behind it. And it wasn’t the main focus. It wasn’t like people living in poverty or an important political constituency who we really want to serve. It was kind of like, well, we’re doing this big thing. We have the majorities we need in Congress, and the support we need from the president at the time was Lyndon Johnson, let’s tack on a smaller thing. That is kind of important, too. But it really was not imagined to be a big deal. Johnson doesn’t even mentioned it in the big speech that he makes about that social security legislation that passes Medicaid and Medicare and 65. And some people call Medicaid, Medicaid like the friendless stepchild of Medicare, it’s like out here over there on the side, and nobody cares about you. But over and so it’s designed in a way that reflects that, like, it’s not universal, the way that Medicare is, instead, Medicaid is only for people who meet certain criteria, you have to be living in or near poverty, initially, you have to have other criteria. Initially, you had to be on what was considered welfare, cash assistance, then, and there are other categorical requirements like maybe if you’re pregnant woman, if you’re a child, if you’re but really only people living in poverty, who then also meet other criteria. So the idea was, this is going to be for a small slice of the most vulnerable people, it’s not going to be a huge resource or investment. And at the start, that was true, but it pretty quickly changed, right? Medicaid was designed to be a program that was going to be partially paid for by states, and also that states would have a lot of control over they would have a lot of discretion over. And so the program grew over time. But very unevenly, I mean, the last state to get a Medicaid program was Arizona in I think, 1981, or 82. So the first state is starting its Medicaid program in 6566. And the last, so there’s a big span of time before we even have it in every state. And then every state is kind of doing a different thing. And that was really only possible because it was a program that wasn’t designed for constituency that was understood to be very politically powerful. So it’s kind of like we’re gonna give you all scraps and you got to take what you can get. That’s changed a lot over time. It has, it hasn’t changed entirely. But efforts to cut Medicaid efforts to pull back efforts at retrenchment have consistently failed. And instead, the program has grown over time. Now because all Medicaid beneficiaries are super politically powerful. In fact, part of what I talk about in my book is reasons why they’re not. But because this is a really great need. And there are some buckets of people in the program who are sympathetic and do who do have some political sway, you know, and so, yeah, it started off as one thing it’s evolved a lot and it’s ever evolved. over, you know, the pandemic brought a real expansion expansion in the sense that more people got on the rolls, because hey, there’s a pandemic, and you want people to have health insurance so that they can get coverage. And also, the federal government said, you know, we’re gonna give states more resources for Medicaid, but we’re gonna require that they don’t churn, they don’t turn people away, or take people off the program. And so that was the status quo for the last few years during the pandemic, pretty soon at the end of, you know, March, that’s no longer going to be the case. And states can start churning people off the press. So this 80 plus million people that we have now that number is going to plummet back down. So to say, this is a program that is ever changing. It’s literally happening right now as we speak. Yeah,

Jenna Spinelle
I’m glad you brought up the kind of political agency and the difference between how the program how Medicare and Medicaid are thought of politically because as you were describing, you know, Medicare is universal on this focus on senior citizens who are and have been a very reliable voting bloc, I’m sure that played into the minds of the legislators who were involved in passing it. But as you tell in the interviews you did for your book, people who are on Medicaid don’t have that same sense of political agency. Can you talk more about that? Where those feelings come from? I think this might be another kind of chicken in the egg situation like, do they feel politically powerless before they started on Medicaid? Or was it a result of being kind of churned up through this system that made them feel like they didn’t have much political agency? In some cases, as you said, there? There are certainly exceptions. But you know, my sense was that broadly, the the sense of agency was fairly low.

Jamila Michener
Yeah, I think that’s right. I mean, baseline people who the vast majority of people who are Medicaid are people who are living in or near poverty, many, not all, but many of those people have a variety of health problems they’re facing. And so these are not the folks that are going to be the most politically active and have the most political agency, right. That being said, even if the baseline isn’t like, this is the group that’s going to be out there engaging politically. One of the things that I point out in the book is the ways that then once you enroll in the program, your experience with the program, itself plays a role in further dampening your political wherewithal. And so when you give people access to a resource they didn’t have before, and they know that resource comes from the state. If they respond politically, it’s not as though Medicaid beneficiaries are just this political last cause. And these are people who were never going to participate anyway, given the right context, the right access to benefits, and then you get health care, maybe that means that you’re less worried. And you can now participate more fully in the life of your community and your polity. There are all sorts of processes and mechanisms that explain this. But the larger point is that a program like Medicaid shapes people’s political lives, and when it’s expansionary, and it’s generous, and it reinforces human dignity, it can draw people into our democracy. And when it’s retrenching and it’s pi V, and it reinforces alienation and stigmatization. It can push people out of our political community. And the book really focuses a lot on that. Since then, I’ve done more research and more thinking around the role of like organizing advocacy and other community organizations grassroots organizing, and that’s another pathway where I’ve seen people bring in Medicaid beneficiaries and activate them, some of these red states where we’ve gotten Medicaid expansion, and we did not expect it. It wasn’t accidental, it was because people organized to get it. And part of the way they did that was not by assuming that Medicaid beneficiaries are somehow naturally powerless, but by thinking about how to build power among that group, and so policy and people organizations can build power among Medicaid beneficiaries, but it doesn’t happen naturally. Right. And policy actually has the power to do the opposite. It can erode and wane the power of beneficiaries, which isn’t good for democracy as a general course of of action.

Jenna Spinelle
Yeah, and, you know, some of those expansions I know happen through ballot measure campaigns, when you know, that’s a very particular type of tool and mechanism. And we’ve seen it happen across several policy areas where states that are stereotypically conservative pass what we might broadly consider progressive policies whether it’s, you know, marijuana legalization or minimum wage increase or changes to to voting policies and procedures and so I guess I wonder if you would consider Medicaid as an instance where the interests of constituents and people are not necessarily aligned with the interests of legislators and the incentives that they have.

Jamila Michener
Yeah, I mean, of course, this really varies by state. And it depends on who the legislators are. But certainly it’s the case that because Medicaid expansion was associated with and came as a part of a larger package of policies through the Affordable Care Act, which is by some pejoratively called Obamacare, and by others, Obamacare is a compliment, right? It depends on where you’re coming from. But because Medicaid expansion was associated with the ACA with Obamacare, and because Medicaid in general, as a policy is associated with being a costly government program, if you are conservative in the sense that you want government to have a smaller footprint, you don’t want to see it growing. Or if you’re partisan, in the sense that you don’t want to support a program that’s associated with President Obama, then you might have reasons political reasons, either ideological or partisan to oppose Medicaid expansion. And that’s what we saw in a lot of different places. And that is very much out of sync with with public opinion more generally, right? There’s wide scale support for Medicaid. In terms of public opinion, it’s only a little less popular than Medicare, which is like pretty astounding, like a lot of people assume that, quote, unquote, poor programs are always going to be stigmatized, and always going to be looked down on. But when we look at public opinion, data focused on Medicaid, it doesn’t look like people’s attitudes towards cash welfare, you know, or even their attitudes towards, quote unquote, food stamps, or SNAP Supplemental Nutrition Assistance Program. Instead, it’s actually much closer to people’s attitudes towards social security and Medicare, not quite there. But pretty close, right? This might have something to do with the fact that, you know, when you survey people, and you ask them, if they have some connection to Medicaid, either personally, because they use it at some point in their lives, or because they know someone close to them, in their immediate circle who uses it, over 70% of Americans have that connection. So this is a program that many people understand matters in the lives of either themselves, or people they love across the life course, you might not need it right now. But when you’re older, and you’re thinking about being in a nursing home facility in a country that has like, basically zero Long Term Care Options, guess what a lot of middle class people when they get elderly and need to be in a nursing home, they’re going to rely on Medicaid did provide their long term care. And so over the life course, a lot of people are connected to Medicaid. And so it’s a pretty popular program. And I think that means that it is in many ways out of sync with what most people want with what many people want, when you oppose Medicaid or you want retrenchment of Medicaid, or you don’t want to expand Medicaid, that’s often not because that’s what the average person wants. It’s because you have political constraints, either ideological or partisan, that make you reluctant around this program. And so it’s a matter of democracy, like where what people want should be reflected in outcomes, right. That’s part of how we think about democracy. And Medicaid is one of those spaces where you can have that disconnect, depending on what state you’re in, which is another aspect of our political system, which is federalism, and how responsive elected officials are to preferences actually varies across place. And so our democracy isn’t just the national thing. There’s a kind of sub national variation in the quality of democracy.

Jenna Spinelle
So I have a few questions for you about federalism. But can you just talk about that definition and how you kind of arrived at it for purposes of this framework you lay out?

Jamila Michener
Yeah, I mean, I draw on a lot of different people to try to think about and conceptualize federalism, I will say, when I first realized that, Okay, I gotta write things about federalism. In this book, I kind of rolled my eyes, I was like, Oh, this is so boring, you know. And then as I got into it, I was like, wow, this is really not boring. This is the heart of how our political system operates. But really, federalism reflects a kind of division of authority in government such that the central government of a national government doesn’t have all of the authority or decision making power. Instead, some of that power also lives in the hands of states. And that’s like constitutionally dictated, right? Like, that’s the 10th Amendment, like states have power. But also in the book, I tried to think about federalism even more broadly than that. And this is really drawing on Lisa Miller, and legal scholars like Heather gherkin, who take federalism right down to the local level, right? And it’s not so much that localities have constitutionally embedded powers like states do. You But many states are giving are delegating power to localities, and certainly no localities are doing the administration of many policies. And so this distribution of power of responsibility of authority across levels of government is really the hallmark of federalism. To be clear, federalism can take many different forms. It’s changed over time, historically in the US, and it’s certainly different in different places. But I think, at the crux of calling this federalism as opposed to something else, right, like just some decentralized power, which is a font a feature of federalism, but it’s really that there is genuine substantive authority at other levels of government, the states can do things that the federal government can, and that the federal government can’t necessarily stop them from doing right, they have real power, right. And that also is true of localities, to a certain extent, to a lesser extent, but a certain extent. So I call it federalism all the way down from the top with the federal government, through states and localities. There’s a different distribution of power and authority. And that has implications for how people experience policy for the way policy is designed and administered, and ultimately implications for democracy.

Jenna Spinelle
And is it possible to square federalism and equality? Or to borrow a phrase from a question I asked earlier? Is inequality baked in to federalism?

Jamila Michener
Yeah, that’s a great question. You know, in some ways, inequality isn’t inherently baked into all kinds of federalism. So for example, some other federal systems not in the US have, like fiscal stabilization measures built into them, right, which means that if one state in the Federation has like dramatically fewer resources than others, the central unit, the central government, may give that state additional resources redistributed more to them to sort of balance things out, right. So there are ways that you can design a federal a federated polity, ways that you can structure federalism so that it is not such an arbiter of our harbinger of inequality, right. But that is not generally what we’ve done in the US. So I don’t want to like impinge federalism as a kind of system in some universal uniform or inherent sense. But as federalism has been built, and expressed and articulated in the context of the US, it has been a medium through which inequality has really been perpetuated. Certainly, this is the case for racism and racial inequality, also the case for economic inequality. And in the book, I focus on the kind of big three, which is racial inequality, economic inequality, and political inequality, right, that you have differential political voice as a result of some of the policies and practices oriented with federalism. But it’s important, I thought, I struggled with this a lot. When I read when I wrote the book, I thought, what’s the point of saying this, because it’s not like federalism is going to change, like it’s a part of our political system. And the more I read about federalism, the more I learned about it, the more I became convinced that like, we’re not suddenly going to have like, some kind of national, everything where federalism goes away. But we can certainly do it differently than we’re doing it now. And we can do it in ways that push back against the kinds of inequality that maybe now we take for granted, that quality of life in Mississippi is going to be dramatically different than quality of life in Minnesota. Maybe now we take for granted that you’re going to have rights and privileges in California and New York that you absolutely do not have in Georgia and Florida. But that doesn’t have to be the case. We can have federalism and not have that.

Jenna Spinelle
And we’ll end here. I know, you mentioned earlier that at the end of March, which we’ll be right when this episode is coming out, there’ll be pandemic related changes to you know, not just Medicaid, as I understand that, but lots of kind of assistance that had been in place during the pandemic will be ending. So can you just, you know, talk more about what that outlook is what the kind of post pandemic relief era looks like, maybe not just for Medicaid, but taken more broadly into some of the other aid areas that were expanded during the pandemic years.

Jamila Michener
Yeah, absolutely. And, you know, I mean, some people are calling it the great unwinding. Because the, during the pandemic, there were a lot of things that sort of were further invested in that were ramped up and that were extended in ways that helped a lot of people. And because I was interviewing people all throughout the pandemic, this really became clear to me people don’t know the nitty gritty of policy. They’re not like this bill and that bill, you know, but they know that suddenly they’re getting more benefits, food benefits that the amount of of SNAP assistance they’re receiving. increases, and they can get some more food for their family or at least offset the growing cost of food. And they know that they’re not having to do as much there’s not as much administrative burden associated with getting help from the government. They know they’re getting emergency rental assistance. So they’re able to stay in their houses, people know that things change, and that it can make their lives like noticeably easier. And this is great unwinding the fact that a lot of the things that we ramped up that we extended that we expanded during the pandemic are now waning, is a huge concern. It means for many people, they’re going to go back to facing even higher levels of precarity. Like they were prior to the pandemic or early in the pandemic, but also people now No, it’s not necessarily Oh, I didn’t have to be living on the brink that way. It was clearly within the ambit of this of the federal government and state governments and local governments to provide these resources. And now I’m just going back to the way it was before many of these people are really hard working people. I mean, I don’t think anybody should starve or not have a roof over their head, whether they’re lazy or hardworking. I think that’s a matter of human dignity. But it’s worth pointing out that many of these folks are not sitting around at home, like I want the largesse of the government, they’re working really hard, getting paid not great wages, dealing with rising food costs, rising housing costs, rising costs of everything that aren’t keeping up with rising wages trying to survive. And during the pandemic, the government, federal, state, local, help them more. And now there’s a decision to stop that. And so people have to live with that their kids have to have less food to eat, they have to have, you know, a harder time keeping a roof over their head and such. And I guess the main, the last thing I would say is that the great unwinding is going to be very uneven. And I know listeners will probably think this lady is obsessed with federalism maybe a little bit, right, because of how much it matters in people’s lives. I’ve worked with some states on how to manage the unwinding. And there are some states that are really working hard to make sure that anybody who is still eligible remains on these programs to really limit the amount of churn the people coming on and off limit, the omitted the additional administrative burden that people face. There are states that are working really hard to do that, because they don’t want to see a mass exodus of people from government assistance programs. And there are states that are just counting down until they can get these people off the assistance. And so where you live is going to be a great determinant of how you experience this great unwinding. And it’s arbitrary, and it’s capricious, and it means that some people are going to face pain, honestly, that they wouldn’t have to if they just lived someplace else.

Jenna Spinelle
Well, Jamila, thank you for your work, shedding light on these issues and helping us think about federalism. In this way, we will link to your book and some of your more recent work in the show notes. So listeners can go check it all out. But thank you so much for joining us today.

Jamila Michener
Thanks for having me, this has been a fun conversation, always love to geek out about federalism.

Chris Beem
That was terrific, and really lays out this book in a very clear and succinct way. I think what is really interesting and distinctive about this book, is how it uses a specific policy question and, you know, innovation to kind of get at this really wooly and complicated and important concept of federalism. And it is, you know, we understand we Americans think about federalism as one of those, you know, really weighty words that we can just throw around and that it kind of like it’s a trump card on conversation. While this is just federalism, right? As we just noted in the last show about juries, right? founders were scared of democracy and scared of giving this power to everybody. But they were also very scared of unrestricted political power. And so federalism was kind of framed as this way to further restrict power, political power, and to make another level of checks and balances, right. So we’ve always had this idea that the states have sovereignty, where how much and how and when it competes with the federal government who wins. These are incredibly fraught questions. They’re incredibly mushy questions. There’s no guidebook that tells you when one wins and when the other wins. And politicians are extremely good at playing both sides. Right. And so when you look at Medicaid as opposed to Medicare, you see this concept in action and you see how kind of Have mushy and inarticulate it is, it’s not going anywhere. federalism is part of our political DNA. But it is also Medicare Medicaid bespeaks just how complicated and politically expedient this concept can be.

Candis Watts Smith 
You use the word mushy that Medicaid kind of illustrates how mushy this business of federalism is. And I think that one way to step back and think about this is something that you said earlier, which is, we have case a Medicaid, we have case B, Medicare, Medicare, as Jamila outlined, was a policy that was intended to be strong, well put together easy to get that it is constructed to be not prestigious program, but it is treated that way. And the people who get Medicare are believed to be and constructed as deserving Medicaid, as she outlined was kind of tacked on and then given to the states. And so, you know, on some level, we might ask ourselves, well, you know, Medicaid is very much a child of federalism. And why, because we were willing to let states do what they pleased for a particular group of people. And there’s another group of people that the federal government said, come hell or high water, we’re going to make sure that they’re okay. So, you know, I think that’s right. I mean, I do think that Medicaid reveals, right, if you walk from one state to another, that your Medicaid benefits and eligibility can change drastically, some people are actually making life decisions around what kind of healthcare they might get under a state Medicaid system. Voting is similar education is similar. I mean, granted, like these are things that are given to the states, like the states have power around voting, the states have power around policing, the states have power around education, the states have power around a lot of things the federal government could, when it wants, Congress get itself together, could do very different things and set baselines and create incentives for states to produce better outcomes. And sometimes they do, and when they don’t, and when they do similarly, we learn what we value as a country. And so you know, the kind of range and complexity that we see Jamila, this book shows that range and complexity influences whether people are going to participate. So it’s not even just kind of like the first order effects of material outcomes for people. But there’s a second set of effects around how people participate in politics, because they are telegraph messages about whether they should, whether they are full citizens, whether they belong in the community, whether they can actually understand what’s going on, you can understand your benefits, can you understand politics enough to be able to make a good decision? So one of the things I appreciate about her unpacking the complexity is that it tells us not just about how well off a group may become or not become, but also what the kind of second order effects on democracy is. And whether people want to participate after dealing with the state dealing with the state’s red tape and dealing with the state’s administrative burdens. That is something worthy of her work as well.

Chris Beem
That’s well said, I think there is a deep and abiding suspicion of poor people. And the suspicion is that they are gaming the system, right? The trope of welfare queens is long standing. And when it comes out, because it does happen, right? When it comes out, it becomes a big story. And you know, there is this. There is not a conservative Christian on Earth in the United States of America, who does not know the verse, the Bible verse, He who does not work, neither shall he eat. Right? This is a very deep idea in American life. And we are an incredibly libertarian country. I have in the last 10 years been to England and South Africa. Those are both lock in countries in their founding in their in their kind of self conception there. are so much more communitarian than the United States of America, we are if you know, I don’t know, maybe Australia, but we are an extremely libertarian country. And if you are that, then your notion is that, hey, you’re responsible for you. And if you are, if you make it, it’s because of you, and if you don’t, is because of you. And so therefore, there’s already this presumption that if you’re poor, that is because of either your moral failure or choices you’ve made. And so you know, you get some, you will find that people are more engaged around questions of children and the disabled, right, because that is something that you can’t necessarily, but certainly you can’t control who you’re born to who your parents are, right. And equality of opportunity is a an important concept in United States politics, at least, you know, it’s as a concept. But, you know, we’re not willing to do the, to make the investments to make equality of opportunity genuine, right, because we’re more worried about somebody gaming the system.

Candis Watts Smith 
So you know, I mean, just going back to, you know, about what we learned and didn’t learn during the pandemic, right. So we have this notion that if you are, there are a lot of people who believe if you are poor, it is because something that you did you have control over this, except the pandemic, it’s kind of similar to the Great Depression, illustrated, that you can be poor because of somebody else’s doing right, or because of the situation or the circumstance. And that became very clear for a lot of Americans very quickly, most Americans do not have enough savings to withstand one month of unemployment. And so that kind of irony is that this kind of idea, and value still is maintained, even after recently learning relearning this lesson, during the pandemic. And I know that we didn’t learn the lesson, because the first kind of talk about unemployment benefits was that we need to end unemployment benefits, because people are not working. The point that I’m trying to make here is that, you know, our ideas about who is deserving, who is morally suspect, who deserves dignity, did not get a full revision and review after the pandemic. And I don’t know, on some level, I just feel like we’re bumping our head against the walls. And this kind of Medicaid unwinding, I think, is just yet another example of how we have yet to learn our lessons around how we can make our values and our priorities match. And maybe our values and priorities do match. Like maybe it’s just that we don’t value people’s health. And so we don’t prioritize it. But it seems like we should, right?

Chris Beem
I think it’s a good note to end on. You know, it speaks to the fact that this isn’t a distinctive, I’m going to use that word again. It’s unusual to have a book about policy that usually only appeals to policy geeks make arguments that are at the core of how Americans understand their government and how they understand the moral implications of their government. So terrific. Great. So I’m Chris Beem.

Candis Watts Smith 
I’m Candis Watts Smith. For Democracy Works, thanks for listening.

 

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