Jamila Michener on the Campbell Conversations

Feb 17, 2018

The Medicaid program was at the center of Obamacare's expansion of health insurance coverage, and the political and legal controversy that followed its passage. It's now seen by many to be at risk in an era of potential social welfare cutbacks. This week, we're joined Jamila Michener, an expert on Medicaid, who has written a book on the subject.

Interview highlights

Grant Reeher (GR): It’s often said that Medicaid is the most poorly understood of the major social welfare programs in this country, and I wanted just to start off by checking in with you. Would you say that’s true? And if so, why would you say it’s true?

Jamila Michener (JM): I completely agree with that. Part of the reason is because there’s a program called Medicare with a very similar name but that is in fact a very different program. And so Medicare, which is the program that provides health coverage to older Americans who are 65 and older…is very different than Medicaid, which is a program that is primarily for low-income Americans to provide them with health coverage, and also for people who have severe disabilities. So that program is means tested and it’s different; it’s not just for everyone below a certain income level. There are a variety of different ways that you become qualified…[Medicaid], despite the fact that it does affect many people—at this point, there are upwards of 70 million people who rely on Medicaid on this country—there are many of us who could go through our whole lives without knowing anyone who’s a Medicaid beneficiary, so it is less salient for many folks.

(GR): Could you say a little bit more about how its fundamental approach is and what it’s trying to accomplish? 

(JM): The fundamental approach of Medicaid is really about making sure that the most vulnerable citizens are able to have access to health insurance, and usually the most vulnerable citizens are those who are low income…often those folks are people who fall into the category of having disabilities or severe chronic illnesses. So, there are some groups of people who may not be as poor…but if you have a severe enough illness, that’s going to mean that your health coverage is going to cost thousands or millions of dollars, you may qualify for Medicaid. So Medicaid is really about covering, providing health insurance coverage, for vulnerable populations—many beneficiaries are children, about 50 percent on average—and making sure that those folks have access to healthcare.

(GR): Now, a much more complicated question. How did Obamacare change the Medicaid program, or at least try to?

(JM): Obamacare tried to change Medicaid by saying instead of the kind of patchwork program that we had where in some states, if you were an adult, you couldn’t qualify for Medicaid, no matter how poor you were. And in other states, you had to be 100 percent of the poverty line, right at the poverty line, and in other states, it was 200. There was this patchwork. Medicaid is an inter-governmental program…The federal government is paying a certain portion of the cost, and that varies depending on which state, and the states are paying the remaining portion…Obamacare tries to provide some sort of uniformity, or a kind of baseline, and the baseline is everybody who’s at 138 percent of the poverty line and below gets Medicaid…regardless of the state…that was the intention of Obamacare, but that’s not what happened…Initially, Obamacare says if you get funds from the federal government for Medicaid…unless you do this, unless you expand the program to everyone below a certain poverty level, we’re going to take away all your [Medicaid] funds [that you’re getting from the national government], which is for billions of dollars…for every single state, that is a very significant part of their budget. And so the threat of having that taken away was a substantial lever for getting compliance from states…Initially covering this additional population that you get through the expansion is free…and as times go by, the federal government will pull back and expect the states to pay more and more of this, but they’ll still be getting a tremendous 90 percent of this covered by this covered by the federal government.

(GR): So then what happens in the story? Now, there’s this lawsuit…and some of the states are not thrilled with getting this help from the national government.

(JM): Enough of the states are not happy about this that they sue. They take this, it ends up going all the way to the Supreme Court. And the Supreme Court says, “Well look, this is essentially you starting a new program…and you’re threatening to take away the existing funds…and that amounts to coercion, so the states don’t really have a choice.” And the Supreme Court says, “This will not go. The states should have the choice, and they don’t lose their existing funds if they choose not to do it.” So now, it’s the Wild West as far as what decisions states will be going to make as far as whether or not to expand Medicaid.

(GR): So now we’ll get to your book. You look at the Medicaid program, and you look at it from the standpoint of those who are using it, or in some cases, trying to use it and not being able to…how’d you get the idea for this project? Why’d you want to do this?

(JM): My research focuses on poverty, inequality, race, with a particular emphasis on how the government shapes life in communities that are low income and disproportionally populated by people of color. I was working on just trying to understand, what does the government mean for folks in these communities? And I started doing interviews. I started talking to people…I went into communities and asked people what was important to them. Medicaid was not on my radar…but it was on theirs. It came up again and again…and I got to a point where I realize it would be disingenuous to not approach it…It’s this behemoth of a program. It’s a labyrinth in terms of the ins and outs, and I thought, can I understand this? But people were trying to figure out how it was working in their lives, and I couldn’t ignore it.

(GR): So let’s get into the findings of your book, here. What did you learn, then, about the effects of Medicaid on the beneficiaries’ views about government and on their political activity and their political senses more generally?

(JM): What I thought I would find is that I’d get an answer one way or the other…and to a certain extent, I found that the overall relationship between Medicaid and different kinds of political participation…that relationship was negative, meaning that people who were enrolled in Medicaid were less likely to do those things…So I thought that was the full story at first. Then, as I talked to people, I realized that they kept talking about place, about where they lived…and I realized that the answer of, well Medicaid has a negative effect, was not the full answer. Because it appeared that the role Medicaid played in people’s lives was varying across place.

(GR): And what would be the factors that would lead to a diminishing of engagement and activity? Was it a fear of, “Hey, if I get involved in stuff, I’m risking losing this,” or what was it?

(JM): It was really about the experience of receiving Medicaid benefits and the messages that that sent to beneficiaries, and those messages were different in different places…When states were taking things away, that made a big difference in people’s lives. Similarly, when states were giving more…those people in the states providing more generous benefits were more likely to participate. So again, when states took away and when they gave, I see political participation move with those kinds of factors.

(GR): There’s been a lot of concern expressed recently that the new tax law that has been passed…there’s another shoe that’s going to drop…it will lead to reductions in the program for one reason or another. Do you see that, do you have that concern, and how would you sort that out?

(JM): I always have that concern with Medicaid. It’s a program that is simultaneously politically strong and politically vulnerable. It’s politically strong on the one hand because some of the recipients of Medicaid are children, folks who are disabled—people we are very sympathetic towards and care about a lot. It’s also politically vulnerable because there are some other people, like non-working adults, who rely on Medicaid who maybe the public doesn’t view in as positive a light…I think when we decide to invest lots of money into lightening the tax load of disproportionally very, very wealthy people and resources are to some extent limited, then the question is, who will lose? In a non-political system, the answer is…those who have the least, and Medicaid beneficiaries inhabit that space. And my findings suggest that many of them…not just that they’re disempowered, but that their very experiences with Medicaid are disempowering them, and unevenly so across place…Then, the ability of a program like Medicaid to sustain itself, to defend itself, is sort of hindered and hampered, so I always worry about that. But I also think that Medicaid has proven resilient, and it’s so important for so many people…that it’s a big target…so it’s no easy thing, but there’s still a certain amount of risk there.