People, Places, Power: Medicaid Concentration and Local Political Participation

Abstract

The geographic concentration of disadvantage is a key mechanism of inequity. In the United States, the spatial patterning of disadvantage renders it more than the sum of its individual parts and disproportionately harms economically and racially marginalized Americans. This article focuses specifically on the political effects of Medicaid beneficiaries being concentrated in particular locales. After offering a framework for conceptualizing the community-wide consequences of such policy concentration, I analyze aggregate multiyear data to examine the effect of Medicaid density on county-level voter turnout and local organizational strength. I find that, as the proportion of county residents enrolled in Medicaid increases, the prevalence of civic and political membership associations declines and aggregate rates of voting decrease. These results suggest that, if grassroots political action is to be part of a strategy to achieve health equity, policy makers and local organizations must make efforts to counteract the sometimes demobilizing "place-based" political effects of "people-based" policies such as Medicaid.

Policy Feedback in a Racialized Polity

“…Social scientists have interrogated a wide spectrum of policy domains with an eye toward race. They have studied welfare, health, education, labor markets, criminal justice, voting rights, and much more (Brown, 1999;Bruch & Soss, 2018;Cohen, 1999;Harris & Lieberman, 2013;Hero & Tolbert, 1996;Katznelson, 2005Katznelson, , 2013Matsubayashi & Rocha, 2012;Michener, 2016;Mink, 1990;Murakawa, 2014;Pager, 2007;Soss et al, 2011;Soss & Weaver, 2017;Tolbert & Hero, 2001;Weaver, 2007;Western, 2006;Williams, 2003). Time and again, such research has confirmed that race is (and has long been) a fundamental factor in explaining policy development, implementation, outputs, and outcomes.…”

“…A substantial and growing body of research has shown that the structure and design of government programs (and the organizations to which they delegate) can influence political decision making across a broad spectrum of actors by channeling resources, generating interests, and shaping interpretive schemas (Barnes, 2018;Béland, 2010;Campbell, 2003Campbell, , 2012Goss, 2013;Mettler & SoRelle, 2014;Mettler & Soss, 2004;Michener, 2018;Morgan & Campbell, 2011;Pierson, 1993;Schneider & Ingram, 1993;Skocpol, 1992;Soss, 2000). In the United States, each of these mechanisms implies a role for race.…”

“…To be sure, scholars recognize the importance of race. In some work, race is not the dominant aspect of the main findings but it is a core feature of the social and political world that scholars consistently foreground in their research (Michener, 2018;Soss, 2000). In other cases, race is acknowledged but included to a more limited extent (Bruch, Ferree, & Soss, 2010;Goss, 2013).…”

“…It can involve imbalances in the racial distribution of policy beneficiaries, incongruences in the proportion of a particular racial group affected by a policy, disparities in benefit size and take-up, and differences in the share of policy benefits that some racial groups receive relative to others. Such racial disproportionalities can affect how policy is constructed by political elites (Bensonsmith, 2005), perceived among the public (Gilens, 1999), experienced by beneficiaries (Lerman & Weaver, 2014a), implemented by bureaucrats (Michener, 2016), funded by government (Garrow, 2012), and made salient by media (Clawson & Trice, 2000;Gilens, 1996). Disproportionality can affect the mechanisms through which policy feedback operates: it funnels policy resources unevenly, serves some interests better than others and influences interpretations of policies.…”

“…and political elites (Barnes, 2018;Barnes & Hope, 2017;Campbell, 2003Campbell, , 2010Goss, 2013;Lerman & Weaver, 2014a;Mettler, 2005a;Michener, 2018;Morgan & Campbell, 2011;Pierson, 1993;Schneider & Ingram, 1993;Skocpol, 1992;Soss, 2000). As the literature on feedback has gained prominence, the theoretical infrastructure undergirding studies of feedback has developed significantly (Béland, 2010;Campbell, 2012;Mettler & SoRelle, 2014;Mettler & Soss, 2004;Patashnik & Zelizer, 2013;Weaver, 2010).…”