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

Public Views on Medicaid Work Requirements and Mandatory Premiums in Kentucky

Importance

Federal and state policymakers continue to pursue work requirements and premiums as conditions of Medicaid participation. Opinion polling should distinguish between general policy preferences and specific views on quotas, penalties, and other elements.

Objective

To identify views of adults in Kentucky regarding the design of Medicaid work requirements and premiums.

Design, Setting, and Participant

A cross-sectional survey was conducted via telephone and the internet from June 27 through July 11, 2019, of 1203 Kentucky residents 9 months before the state intended to implement Medicaid work requirements and mandatory premiums. Statistical analysis was performed from October 2019 to August 2023.

Main Outcomes and Measures

Agreement, disagreement, or neutral views on policy components were the main outcomes. Recruitment for the survey used statewide random-digit dialing and an internet panel to recruit residents aged 18 years or older. Findings were weighted to reflect state demographics. Of 39 110 landlines called, 209 reached an eligible person (of whom 150 participated), 8654 were of unknown eligibility, and 30 247 were ineligible. Of 55 305 cell phone lines called, 617 reached an eligible person (of whom 451 participated), 29 951 were of unknown eligibility, and 24 737 were ineligible. Internet recruitment (602 participants) used a panel of adult Kentucky residents maintained by an external data collector.

Results

Percentages were weighted to resemble the adult population of Kentucky residents. Of the participants in the study, 52% (95% CI, 48%-55%) were women, 80% (95% CI, 77%-82%) were younger than 65 years, 41% (95% CI, 38%-45%) were enrolled in Medicaid, 36% (95% CI, 32%-39%) were Republican voters, 32% (95% CI, 29%-36%) were Democratic voters, 14% (95% CI, 11%-16%) were members of racial and ethnic minority groups (including but not limited to American Indian or Alaska Native, Asian, Black, Hispanic or Latinx, and Native Hawaiian or Pacific Islander), and 48% (95% CI, 44%-52%) were employed. Most participants supported work requirements generally (69% [95% CI, 66%-72%]) but did not support terminating benefits due to noncompliance (43% [95% CI, 39%-46%]) or requiring quotas of 20 or more hours per week (34% [95% CI, 31%-38%]). Support for monthly premiums (34% [95% CI, 31%-38%]) and exclusion penalties for premium nonpayment (22% [95% CI, 19%-25%]) was limited. Medicaid enrollees were significantly less supportive of these policies than nonenrollees. For instance, regarding work requirements, agreement was lower (64% [95% CI, 59%-69%] vs 72% [95% CI, 68%-77%]) and disagreement higher (26% [95% CI, 21%-31%] vs 20% [95% CI, 16%-24%]) among current Medicaid enrollees compared with nonenrollees (P = .04). Among Medicaid enrollees, some beliefs about work requirements varied significantly by employment status but not by political affiliation. Among nonenrollees, beliefs about work requirements, premiums, and Medicaid varied significantly by political affiliation but not by employment.

Conclusions and Relevance

This study suggests that even when public constituencies express general support for Medicaid work requirements or premiums, they may oppose central design features, such as quotas and termination of benefits. Program participants may also hold significantly different beliefs than nonparticipants, which should be understood before policies are changed.

How Low-Paid Parents Navigate The Complex Financial Landscape Of Benefits Cliffs And Disincentive Deserts

Policy makers are concerned that benefits cliffs-the phenomenon by which low-paid workers abruptly lose public benefits as their wages increase-may disincentivize work. The related concept of disincentive deserts refers to occasions when pay increases have little or no effect on a worker's financial well-being because of the resulting gradual reductions in public benefits. Little is known about how low-paid workers navigate this complex financial terrain. Based on in-depth interviews with twenty-five low-paid parents, this article reveals that parents' decisions about how much to work when facing benefits cliffs and disincentive deserts are based on their nuanced assessments of their currently available resources-financial, material, and emotional-of which public benefits are just one small piece. The primary driver of parents' decision making is their ability to care for their families. In no case did they base their decisions solely on a particular wage, income level, or ability to maintain public benefits. Thus, economic modeling, which draws conclusions about the impact of public benefits policies based solely on financial resources from work and benefits, is insufficient for understanding how parents make difficult choices when time, stress, and health are also relevant factors. The article concludes with recommendations for policy makers to expand and simplify public benefits.

Health Equity and the Dynamism of Structural Racism and Public Policy

Policy Points Both public policy and structural racism are dynamic systems that reinforce each other. Efforts to address the health effects of structural racism must account for the nature of these systems. Politics and policy are critical for understanding the persistence of racial health inequities and creating policies and interventions that can mitigate the effects of structural racism on health.

Politics, power, and precarity: how tenant organizations transform local political life

As the coronavirus pandemic exacerbated housing precarity, tenant organizations grew in numbers and salience. But membership-based tenant organizations predated the pandemic and will persist beyond it. There are (at least) hundreds of them in localities across the country. Many aim to advance sweeping change. In doing so, they face formidable tasks: politically organizing in race-class subjugated communities, working in opposition to powerful actors (corporate landlords, property managers, etc.), and navigating complex and sometimes hostile local political institutions (city councils, mayors, rent boards, etc.). How do these organizations build power and effect change in the face of such obstacles? Drawing on a rich body of original qualitative evidence (participant observation and in-depth interviews), this paper explores the politics of local tenant organizations. We assess the origins of such organizations, how they are structured, and how they pursue political change. In doing so, we offer a rich descriptive account of phenomena that have largely escaped the attention of political scientists. We find that tenant organizations can cultivate radically different ways of conceptualizing political economy, carve out a distinctive political focus on race-class subjugated communities, and create critical opportunities for otherwise marginalized actors to develop and exercise political power.

Invisible and unequal: Unincorporated community status as a structural determinant of health

Despite increasing awareness of the importance of political determinants of health, place-based research has not interrogated one of the most common political statuses: the impact of living in a community without municipal incorporation. In 2010 an estimated 37% of the U.S. population lived in an unincorporated area; despite their ubiquity, unincorporated communities are largely absent from the public health literature. Residents of unincorporated areas typically do not have their own local (e.g., city or municipal) government. This lack of representation leads to political exclusion and diminished access to resources, especially for low-income communities of color, Furthermore, by not disaggregating health data to unincorporated communities, residents are subsumed into county or census tract data that may not be reflective of their community's composition or context. Without jurisdictional distinction in research, there is no accountability for the manufacturing of health inequities in unincorporated communities . In the absence of empirical research on unincorporated communities, this paper uses the Commission on Social Determinants of Health (CSDH) Framework of the World Health Organization to argue that lack of municipal status is a structural determinant of health responsible for social conditions which generate cumulative health risks for residents. This includes using existing evidence on social conditions typical of unincorporated communities to describe patterns of residential segregation, neighborhood disadvantage, and environmental hazards that may increase residents' exposure to unhealthy environments in unincorporated communities. Finally, we provide an agenda for future public health research that can begin to address this health and racial equity gap for low-income unincorporated communities of color who have, until now, been absent in health equity discourse.

Affordable but Inaccessible? Contraception Deserts in the US States

CONTEXT

This article focuses on whether, and the extent to which, the resources made available by Title X-the only federal policy aimed specifically at reproductive health care-are equitably accessible. Here, equitable means that barriers to accessing services are lowest for those people who need them most.

METHODS

The authors use geographic information systems (GIS) and statistical/spatial analysis (specifically the integrated two-step floating catchment area [I2SFCA] method) to study the spatial and nonspatial accessibility of Title X clinics in 2018.

FINDINGS

The authors find that contraception deserts vary across the states, with between 17% and 53% of the state population living in a desert. Furthermore, they find that low-income people and people of color are more likely to live in certain types of contraception deserts.

CONCLUSIONS

The analyses reveal not only a wide range of sizes and shapes of contraception deserts across the US states but also a range of severity of inequity.

Lingering Legacies: Public Attitudes about Medicaid Beneficiaries and Work Requirements

CONTEXT

This article provides a detailed picture of the mindset of Americans about Medicaid work requirements and the important roles that perception of deservingness and racial bias play in public attitudes.

METHODS

The authors conducted a large original survey to investigate public attitudes toward work requirements. They analyzed the predictors of overall support for work requirements, correlates of who should be exempt from them, and attitudes toward work supports that make compliance with work requirements easier.

FINDINGS

The authors found that public opinion is split relatively evenly when it comes to Medicaid work requirements in the abstract. When Americans are confronted with the complexities of the issue, important nuances emerge. The authors also found consistent evidence that support for work requirements is higher among conservatives, those who see Medicaid as a short-term program, and racially resentful non-Hispanic whites. They show that groups that have historically been framed as deserving see high levels of support for their exemption (e.g., the disabled and senior citizens). Finally, the authors found that Americans are supportive of policies that provide individuals with help when transitioning into the workforce.

CONCLUSIONS

Americans' views of Medicaid and the populations it serves are complex and continue to be influenced by perceptions of deservingness and race.

The Affordable Care Act in the States: Fragmented Politics, Unstable Policy

Many argue that the frustrated implementation of the 2010 Affordable Care Act (ACA) stems from the unprecedented level of political polarization that has surrounded the legislation. This article draws attention to the law's "institutional DNA" as a source of political struggle in the 50 states. As designed, in the context of US federalism, the law fractured authority in ways that has opened up the possibility of contestation and confusion. The successful implementation of the ACA varies not only across state lines but also across the various components of the law. In particular, opponents of the ACA have experienced their greatest successes when they could take advantage of weak preexisting policy legacies, high levels of institutional fragmentation, and negative public sentiments. As argued in this article, the fragmented patterns of health care politics in the 50 states identified in previous research have largely persisted during the Trump administration. Moreover, while Republicans were unsuccessful at repealing the legislation, the administration has taken advantage of its structural deficiencies to further weaken the legislation's capacity to expand access to affordable, quality health insurance.

Does Group Deliberation Mobilize? The Effect of Public Deliberation on Willingness to Participate in Politics

Proponents of public deliberation suggest that engaging in deliberation increases deliberators' subsequent participation in other forms of politics. We evaluate this "deliberative participation hypothesis" using data drawn from a deliberative field experiment in which members of medically underserved communities in Michigan deliberated in small groups about the design of that state's Medicaid program. Participants were randomly assigned to deliberate about the program in a group or to think about the decision individually, and then completed a post-survey that included measures of willingness to engage in a variety of political acts. We measured willingness to engage in common forms of political participation, as well as willingness to participate in particularistic resistance to adverse decisions by insurance bureaucracies. Contrary to the claims of much of the existing literature, we find no impact of deliberation on willingness to engage in political participation. These results suggest that the ability of public deliberation to increase broader political engagement may be limited or may only occur in particularly intensive, directly empowered forms of public deliberation.

Addressing Health Equity in Public Health Practice: Frameworks, Promising Strategies, and Measurement Considerations

This review describes the context of health equity and options for integrating equity into public health practice. We first discuss how the conceptualization of health equity and how equity considerations in US public health practice have been shaped by multidisciplinary engagements. We then discuss specific ways to address equity in core public health functions, provide examples of relevant frameworks and promising strategies, and discuss conceptual and measurement issues relevant to assessing progress in moving toward health equity. Challenges and opportunities and their implications for future directions are identified.

THE IMPACT OF MEDICAID EXPANSION ON VOTER PARTICIPATION: EVIDENCE FROM THE OREGON HEALTH INSURANCE EXPERIMENT

In 2008, a group of uninsured low-income adults in Oregon was selected by lottery for the chance to apply for Medicaid. Using this randomized design and state administrative data on voter behavior, we analyze how a Medicaid expansion affected voter turnout and registration. We find that Medicaid increased voter turnout in the November 2008 Presidential election by about 7 percent overall, with the effects concentrated in men (18 percent increase) and in residents of Democratic counties (10 percent increase); there is suggestive evidence that the increase in voting reflected new voter registrations, rather than increased turnout among pre-existing registrants. There is no evidence of an increase in voter turnout in subsequent elections, up to and including the November 2010 midterm election.

Organizing seniors to protect the health safety net: the way forward

Over the past century, the organized voice of seniors has been critical in building the U.S. health safety net. Since the 2016 election, that safety net, particularly the Medicaid program, is in jeopardy. As we have seen with the rise of the Tea Party, senior support for health care programs-even programs that they use in large numbers-cannot and should not be taken for granted. This article provides a brief history of senior advocacy and an overview of the current senior organizing landscape. It also identifies opportunities for building the transformational organizing of low-income seniors needed to defend against sustained attacks on critical programs. Several suggestions are made, drawn from years of work in philanthropy, advocacy, and campaigns, for strengthening the ability to organize seniors-particularly low-income seniors-into an effective political force advocating for Medicaid and other safety net programs.

The Politics of Medicaid: Most Americans Are Connected to the Program, Support Its Expansion, and Do Not View It as Stigmatizing

Policy Points: More than half of Americans are connected to the Medicaid program-either through their own coverage or that of a family member or close friend-and are significantly more likely to view Medicaid as important and to support increases in spending, even among conservatives. This finding helps explain why Affordable Care Act repeal efforts faced (and will continue to face) strong public backlash. Policymakers should be aware that although renaming programs within Medicaid may have increased enrollment take-up, this destigmatization effort might have also increased program confusion and reduced support for Medicaid even among enrollees who say the program is important to them.

CONTEXT

Since the 1980s, Medicaid enrollment has expanded so dramatically that by 2015 two-thirds of Americans had some connection to the program in which either they themselves, a family member, or a close friend is currently or was previously enrolled.

METHODS

Utilizing a nationally representative survey-the Kaiser Family Foundation Poll: Medicare and Medicaid at 50 (n = 1,849)-and employing ordinal and logistic regression analyses, our study examines 3 questions: (1) are individuals with a connection to Medicaid more likely to view the program as important, (2) are they more likely to support an increase in Medicaid spending, and (3) are they more likely to support adoption of the Medicaid expansion offered under the Affordable Care Act? For each of these questions we examine whether partisanship and views of stigma also impact support for Medicaid and, if so, whether these factors overwhelm the impact of connection to the program.

FINDINGS

Controlling for the strong effect of partisanship, people with any connection to the Medicaid program are more likely to view the program as important than those with no connection. However, when it comes to increasing spending or expanding the program, the type of connection to the program matters. In particular, adults with current and previous Medicaid coverage and those with a family member or close friend with Medicaid coverage are more likely to support increases in spending and the Medicaid expansion; but, those connected to Medicaid only through coverage of a child are no more likely to support Medicaid than those with no connection.

CONCLUSIONS

Future research should probe more deeply into whether people with different types of connection to Medicaid view the program differently, and, if so, how and why. Moreover, future research should also explore whether state-level attempts to destigmatize Medicaid by renaming the program also serves to reduce knowledge and support for Medicaid.