In June 2012, the Supreme Court upheld the core of the Affordable Care Act but said that each state could decide whether or not to implement a core provision, the expansion of Medicaid to cover low-income people just above the poverty line. That judicial development triggered partisan battles over Medicaid expansion. More than two dozen states have agreed to take federal funds to enroll more people in Medicaid, but twenty-three states led by Republicans are so far refusing.
As the battles rage on, the people we almost never hear from are those currently enrolled in Medicaid. Why? The easy answer is that many of those who utilize Medicaid are poor, and impoverished Americans participate less readily than others in elections and other arenas of democracy. But in addition to low levels of income and educational attainment, could there be something about Medicaid itself that discourages many beneficiaries from active political participation? My research looks into this question, asking how poor people’s experience of receiving Medicaid influences their political outlooks and participation in democratic citizenship. The findings are in many ways troubling – and they underscore the impact of varied experiences with Medicaid and associated social and institutional realities in different U.S. states.
Social Programs and Democratic Citizenship
Why would anyone think that Medicaid could influence the political participation of those who receive benefits? Scholars have learned that government programs can influence civic and political engagement by channeling resources, mobilizing interests, and shaping people’s perceptions of government and their own capabilities as citizens. Still, when I began interviewing unemployed inner city residents of Chicago in 2009, Medicaid was not on my radar. It only emerged as the people I spoke with talked about the challenges of securing health benefits for themselves and their families. Over the course of dozens of interviews, beneficiaries voiced an acute awareness of the direct part that government played in determining their access to health services. For many of them, Medicaid affected vital and sometimes intimate aspects of their lives. One male research participant, for example, refused to marry his high school sweetheart out of fear the he would lose his Medicaid coverage, and consequently lose access to treatments for a life threatening chronic health condition. Such situations were not uncommon, as my respondents were often quite articulate about the profound influence of government-funded health benefits on their lives.
A Study of Medicaid’s Political Impact
A key part of my research involved the analysis of quantitative data on political attitudes and participation from three national surveys with large samples of respondents. Overall, I found that people receiving Medicaid benefits are significantly less likely to participate politically than people with similar social characteristics who are not getting Medicaid benefits. Medicaid recipients are less likely to register to vote, less likely actually to vote, and less likely to take part in civic activities such as contacting government officials, attending a rally, or joining a community group. Nevertheless, there were important differences in the degree to which receiving Medicaid was associated with lower levels of political participation – differences attributable to the varied social and institutional realities in the states where beneficiaries live. Focusing only on Medicaid beneficiaries, political engagement is higher among those living in states with:
- less extreme geographic disparities in health indicators
- recent expansions in Medicaid benefits
- a broader range of health services covered by Medicaid (things like dental and vision)
- higher levels of political participation among low-income populations and racial minorities
These findings held up even after I used advanced statistical techniques to take into account other experiences disadvantaged people on Medicaid may have – such as receiving welfare, serving time in prison, dependence on drugs, serious health difficulties, or coping with the needs of large families.
In addition, my research went beyond the numbers to hear what Medicaid beneficiaries have to say. For example, Margie, a Chicago woman, scoffed at the idea of the American dream:
“The American nightmare is still a fact. I have to go to the doctor every three months and I have to have pills every day. Sometimes you have to choose between medicine and food. Medicaid… it was just so much [hassle] I left there... But it’s looking like I’m gonna have to go and stand in somebody’s line to get some medical help. That’s why when you ask me about the government, I say I don’t know what’s going on there. I don’t approve... I’m sure there’s something we can do. Like vote. It’s supposed to be making a difference if you vote… but we vote for everything and we don’t get it.”
For people like Margie, “geographic health disparities” come alive and influence how they perceive government programs. For example, when Medicaid beneficiaries perceive drastic differences in quality between health clinics located in their neighborhoods and those located in more affluent areas, such perceptions can influence their assessment of Medicaid and their sense of government as a source of help or hindrance. Many poor people see government as unlikely to listen to them or cater to their needs, and such perspectives are easily reinforced by worrisome experiences with Medicaid – even if the benefits themselves are much needed and truly helpful.
A More Complete Understanding of Social Policies
What larger considerations should we take from these findings? Clearly, government programs meant to improve the health of the poor also have an impact on the wellbeing of our democracy. And variations among the fifty states matter, especially when states play a large role in carrying through programs such as Medicaid. So far, participating in Medicaid has a discouraging effect on citizen engagement – but the damage is much less evident in U.S. states with more health equity, more generous benefits and more inclusive politics where citizens from many backgrounds regularly participate.