Medicaid and the Policy Feedback Foundations for Universal Healthcare

Date01 September 2019
AuthorJamila Michener
Published date01 September 2019
Subject MatterPrescriptions: Health Care
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The Annals of the American AcademyMedicaid and Universal Healthcare
Public policies are products of politics, but they also
feed back into the political system by shaping the
actions and attitudes of members of the polity. To date,
scholarly examinations of feedback processes have
been mostly concerned with understanding the rela-
tionship between public policy and democracy; rela-
tively little attention has been paid to connecting policy
feedback to the practical questions that animate poli-
tics. This article examines policy feedback as it applies
Medicaid and to efforts aimed at achieving universal health coverage
in the United States—a widely held policy goal shared
the Policy
by a majority of American voters across partisan lines. I
argue that in the contemporary political context,
Medicaid—a pillar of the American healthcare system
and the primary mechanism for insuring low-income
and disabled citizens—can produce negative feedbacks
Foundations for that demobilize political action, destabilize advocacy
groups, and deter coalition building. Together, these
feedbacks undermine future possibilities for universal
healthcare. After detailing these democratic dilemmas,
I outline strategies for proactively addressing them.
Keywords: policy feedback; Medicaid; universal
healthcare; negative feedback
Public policies can affect the trajectory of
politics. This intuitive and astute observation
forms the basis for a body of scholarship that
systematically charts the political effects of pub-
lic policy—a process known as policy feedback
(Béland 2010; Campbell 2003, 2012; Lerman
and Weaver 2014; Mettler 2005; Mettler and
Soss 2004; Michener 2018; Patashnik and Zelizer
2013; Pierson 1993; Skocpol 1992; Soss 2000).
Ideally, insights about policy feedback processes
can be thoughtfully applied to illuminate press-
ing problems in the world. Yet even as scholarly
Jamila Michener is an assistant professor in the
Department of Government at Cornell University.
She is author of Fragmented Democracy: Medicaid,
Federalism and Unequal Politics (Cambridge University
Press 2018).
DOI: 10.1177/0002716219867905
AAPSS, 685, September 2019

knowledge of policy feedback grows in nuance and scope, it may not translate into
relevant or useful information beyond the pages of academic books and journals.
The translational prospects of policy feedback research depend on the extent to
which scholars make their findings legible to wide audiences and relevant to real-
world dilemmas (Hacker 2010). This article is one step in that direction. I leverage
ideas from the policy feedback literature to think prospectively about how contem-
porary Medicaid politics is laying the groundwork for the future of health policy.
This move from academic theorization and measurement to practical engagement
with the world—though fraught in some ways—is a productive effort to confront
“the problems and questions that govern our horizons as scientists of politics and
policy in a nation whose tradition, language, and aspirations claim to be demo-
cratic” (Farr, Hacker, and Kazee 2006, 586).
In view of that goal, I argue that after the Affordable Care Act (ACA) became
U.S. law, Medicaid politics prompted (at least) three negative feedback processes.
If exacerbated and neglected, this negative feedback can hinder future efforts to
expand access to healthcare. These matters have clear partisan implications.
However, negative feedback is crucial for reasons that transcend strategic partisan
calculations. Policy feedback that stymies political engagement, weakens political
organizations, and hampers coalition building risks subverting (small-d) demo-
cratic policy outcomes. My arguments in this article hinge on the presupposition
that, irrespective of any particular partisan implications, undermining participa-
tory democracy is undesirable. In light of that assumption, I end the article with
suggestions for strategies to counteract negative Medicaid feedback effects.
The Goal of Universal Healthcare: Why Medicaid Matters
According to a recent national survey by the Pew Research Center, six in ten
Americans say that it is the federal government’s responsibility to make sure all
Americans have healthcare coverage (Kiley 2018). Perhaps even more strikingly,
a 2018 Reuters-Ipsos survey found that 70 percent of Americans now support
“Medicare for all,” including 85 percent of Democrats and 52 percent of
Republicans (Stein, Cornwell, and Tanfani 2018). Notwithstanding such biparti-
san support, universal coverage policies are commonly perceived as politically
infeasible (Brooks 2019; Faris 2017; Hiltzik 2016; Kelly and Alesci 2019;
Robinson 2019; Siegel 2018; Stolberg and Pear 2019; Waldman 2018). Certainly,
practical barriers like costs and administrative complexity make universal cover-
age a daunting goal. Nonetheless, many analysts agree that the most crucial
dynamics of health policy are determined by politics (Hacker 2008, 2018; Grogan
and Park 2017b; Mayer, Kenter, and Morris 2015; Rigby, Clark, and Pelika 2014;
Rigby and Haselswerdt 2013; Roper 2007). Policy feedback scholars can thus
contribute useful knowledge about the path toward universal healthcare by
thinking critically about how existing policies create politics.
To that end, this article focuses on the policy feedback implications of
Medicaid. Medicaid is a pillar of the American health care system. As the single

largest public health insurer in the United States, Medicaid provides health cov-
erage for upwards of 72 million Americans (Centers for Medicaid & Medicare
Services 2019). Given its size and scope, the future of any healthcare policy
transformation likely pivots on the current-day status and effects of Medicaid
policy. The political effects of Medicaid are especially germane. Recent research
demonstrates that Medicaid affects political outcomes such as voting, participat-
ing in political groups, and policy attitudes (Clinton and Sances 2018; Haselswerdt
2017; Haselswerdt and Michener 2019; Hopkins and Parish 2018; Michener
2017, 2018). Medicaid policy shapes the political attitudes and actions of both
individuals and organizations (Michener 2018). Given its role in producing the
political conditions that structure the trajectory of health policy, Medicaid is cen-
tral to assessing a route toward a robust universal healthcare system in the United
States. Importantly, Medicaid’s intergovernmental design, its development in the
wake of the ACA, and its status in the larger healthcare system pose distinct
policy feedback dilemmas. In the pages that follow, I outline these challenges and
describe how the post-ACA context risks eroding the political foundation on
which Medicaid rests and, thereby, makes universal healthcare a heavier political
lift. I offer both offensive and defensive approaches to addressing this predica-
ment. The problems I point to are difficult, and silver bullet solutions do not
exist. Still, I sketch three strategies for diffusing negative policy feedback and
generating positive feedback. I primarily emphasize states but also keep an eye
toward national policy and politics.
Contemporary Healthcare Politics and Medicaid
Policy Feedback
The politics of healthcare has grown even more explosive and polarized in the
wake of the 2010 ACA. This is especially true with regard to Medicaid, a policy
that reflects both the promise and peril of healthcare in the United States. In the
last few years, we have seen vigorous efforts at the national and state levels to
erode Medicaid. The 115th Congress attempted to advance a parade of unpopu-
lar “repeal and replace” policies. Though these policies had quite anodyne names
such as the “American Health Care Act” and the “Better Care Reconciliation
Act,” they were each marked by a forceful drive toward large cuts to Medicaid.
According to projections from the Congressional Budget Office, the repeal and
replace policies would have led to tens of millions of people being uninsured,
many as a result of reductions in Medicaid coverage via the imposition of per
capita caps or block grants (Jost 2017). In response to threats to Medicaid fund-
ing, there was striking pushback from a wide range of stakeholders who stood to
lose substantially if Medicaid were weakened (Cancryn 2017; Cancryn and
Demko 2017; Michener 2018; Sarlin 2017; Stein 2017; Subberwal 2017). Such
groups included program beneficiaries, doctors, hospitals, insurance companies,
and organizations representing disabled and elderly Americans who count on
Medicaid for their survival and long-term care.

The partisan political episodes around “repeal and replace” efforts made it
pointedly clear that neither Medicaid’s entrenchment nor its popularity will
secure its political viability. Threats of cuts have loomed large even as Medicaid
garners support from 74 percent of Americans, including 65 percent of
Republicans.1 Medicaid is an undoubtedly vital lifeline for tens of millions of
Americans. Researchers have quantified the number of lives it saves and meas-
ured its effects on outcomes ranging from poverty to education to crime

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