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Health Affairs This Week places listeners at the center of health policy’s proverbial water cooler. Join editors from Health Affairs, the leading journal of health policy research, and special guests as they discuss this week’s most pressing health policy news. All in 15 minutes or less.
Hello and welcome to Health Affairs This Week. I'm your host Jeff Beyers. We're recording on 08/12/2025. I know I talked a lot about some events coming at you last week when we had another podcast. So just to highlight two real quick, we have some free and exclusive insider events coming at you on August 26, a free virtual event.
Jeff Byers:We'll explore independent dispute resolution for our provider prices in the commercial sector series. And then, mark your calendars on September 23. For insiders, we have a panel to discuss prior authorization, which includes Mark Vendrick, Ravi Gupta, Michael Ian Kyle, and Christina Andrews. Join us then. Today on the pod to talk about political power, we have Jamila Michener from Cornell University.
Jeff Byers:Jamila, welcome to the program.
Jamila Michener:Thank you. I'm excited to be here talking about this.
Jeff Byers:Medicare and Medicaid hit its sixtieth birthday recently. We have a couple of articles on forefront that touch on that topic. You wrote on forefront at the July, an article titled The Future of Medicaid and the Imperative of Organized Power. We're gonna be talking about that and more today. I implore all the listeners to check out that article.
Jeff Byers:So I know you had some thoughts about Medicaid through the lens of political power. So every episode can be someone's first. Maybe it's their first to health policy. Maybe it's their first to poli sci. Shout out to all the poli sci majors out there.
Jeff Byers:What do you refer to when you refer to political power?
Jamila Michener:Yeah. I love that we just shouted out poly sci majors. That might be my love language. No. Yeah.
Jamila Michener:Definitional clarity is always a good place to start. I will say this. Power is one of those things that political scientists spend a lot of time theorizing studying, and there are a lot of complex definitions one could draw out. But I think of power and talk about it in the context of this topic in a really straightforward way, which is how much capacity do you have to affect the circumstances that are shaping your own life or the lives of the people around you and your community through the tools of the political system. So if you can use the tools of the political system in a way that maybe not in any given one off situation, but in a way that over time consistently and regularly gives you the ability to shape the circumstances of your life and your community.
Jamila Michener:If you can do that, then you have power. But if you can use the tools of the political system and it yields nothing, it doesn't change anything about your life even over a medium to long term, then you don't. And if you're not able to use the tools of the political system, if those tools are not available to you for some reason or the other, then you also don't. So can you use the tools of the political system, voting, mobilizing in a variety of ways, narrative discourse, lobbying. There's those are there are lots of tools.
Jamila Michener:I just named some. I could name more. But if you can use those tools and whatever combination to change the circumstances that affect your life, then you have some degree of power.
Jeff Byers:Well, great. Thank you for that definitional upfront of tools and of political power. So now that we got those definitions out of the way, how does this political power manifest itself in a program such as Medicaid? Like how does that power affect policies? How does it affect beneficiaries?
Jamila Michener:I love that you're asking this because when I first started studying Medicaid as a political scientist, I would give presentations and talks and I would say I'm talking about Medicaid and people would assume that I only wanted to focus on the policy side of things. Like let's talk about the nuts and bolts of Medicaid policy. And I am a Medicaid geek. I love to talk about the nuts and bolts of Medicaid policy just as much as any other Medicaid geek would love that. But what I would say, well, I wanna talk about politics and I wanna talk about power.
Jamila Michener:You know, I often got pushed back and people would say, well, let's not politicize this program. It's not a political issue. It's about healthcare. This idea that power for example is a bad word and it's not something that we want to make a social program like Medicaid about. Medicaid is about giving people access to healthcare and health insurance.
Jamila Michener:It's not about resting some kind of power grab, right? But the reality is that Medicaid requires an immense amount of resources. It requires a real commitment from a government and its people to invest in health in a very particular kind of way in a way that ensures that even the most economically or health vulnerable among us are able to access care. And that kind of investment, we're talking about hundreds of billions of dollars a year and over the long term much more, that doesn't come for free politically. It always requires political contestation.
Jamila Michener:There are people that would rather pay lower taxes or would rather have their pet project invested in. And so why are we gonna spend resources helping low income people, chronically ill people, and so forth to have access to health care when we could spend those resources on something else? Well, we could do it out of the goodness of our hearts, the kindness of our hearts. But often the kindness of our hearts does not win politically. And what wins is power.
Jamila Michener:And so power matters for Medicaid because power determines how our resources get distributed and Medicaid requires the redistribution of resources.
Jeff Byers:So you talked about power makes a difference of what we spend time on, which kind of relates to a follow-up I had about making choices. But I wanna ask go back real quick before moving on with more Medicaid stuff. How do you think about the idea you've heard you said you got pushed back on when talking about power. Do you get a sense that some people are demure about talking about power, especially in the context of the health care and why might that be?
Jamila Michener:I mean, I think that's exactly right that people can be sometimes unintentionally and sometimes intentionally strategically, demure is a great way to put it, hesitant about making it about power for a couple different reasons. First is sometimes people confuse power with partisanship. And they think, oh, if people start to think Medicaid is about partisanship, like Democrats are for Medicaid, Republicans are against Medicaid, then Medicaid ends up caught in that same polarized battle that we see characterizing so much of our politics today, and people are worried about that. They don't want our health insurance and other social programs to be hurt by association with political parties or political movements that catalyze polarization. Right?
Jamila Michener:And and I can understand that. The reality, however, is that Medicaid gets caught up in some of those dynamics regardless. And another reality though is that Medicaid is not straightforwardly partisan. Democrats and Republicans rely on it. And so Medicaid is about power who gets to have influence over how resources are distributed.
Jamila Michener:And that affects partisan dynamics, but it is not encapsulated in them. And so but I think people have fears about things like that. If we politicize this thing, it can become polarized. And now we won't be able to agree on even the basics of what we you know, and and and that's a real risk and I understand it. I just don't think it's one of those things that putting our heads in the sand is gonna make the problem go away.
Jeff Byers:Yeah. So potentially that aversion to talking about power could actually, like, make the thing happen that you don't wanna happen. Is that what you're saying? I'm if I'm correct.
Jamila Michener:Exactly. Where you're like, well, you'd if you don't acknowledge that power plays a role and you're not intentional about thinking about where and how power is cultivated, it will still operate. It just won't operate in a way that we're being intentional and and and thoughtful about, you know.
Jeff Byers:Yeah. As the world turns. So you argue that the design and structure of Medicaid has an enduringly presupposed, and reinforced limited power on the part of many of the people who directly rely on the program and communities that are mostly directly affected by it. You kinda mentioned that in the last answer. But specifically, what do you what do you mean by that?
Jamila Michener:A few different things when we start to think about power and use it as a kind of lens to assess Medicaid. If you think about the early development of Medicaid, how Medicaid came to be as a program in 1965, it was really a top down process. It wasn't as though anyone was like, well, let's talk to low income people or people who have a vulnerable health status. Let's see what kind of program they need and want. And let's try to respond to their needs and their voices because they're able to exercise power and develop and design a program based on that.
Jamila Michener:That is not anyone who knows the deep history of Medicaid knows that is not what happened. Right? Medicare, which is our our health program for people who are 65 and older, that was something that political officials had to be very attentive to because there was a the political stakes, the fact that they could be voted out of office if they didn't make the right choice, that was really clear. And so we thought a lot about how to design Medicare in a way that was easy and accessible and would be a positive experience for people. Medicaid for low income people was a kind of afterthought and it was designed in a top down way driven by mostly elites who who were never going to experience the program that they were designing even if they had good intentions.
Jamila Michener:And so from the beginning, you see how this imbalance in power shapes whether Medicaid even comes into existence and how it comes into existence. So we design a program that's means tested, that's different in different places. We give states lots of discretion so that you can't really rely on what you have. We design a program that that we don't expect to be easy for people, that we don't expect to be accessible when Medicaid was first stood up. Nobody thought it would become this massive behemoth in terms of numbers, 70 plus million people that it is now.
Jamila Michener:It wasn't designed for mass accessibility. It was designed for, well, those people at the margins that we don't exactly wanna leave them to, you know, absolute squalor, but they weren't the centerpiece and their voices and input wasn't what was driving the process.
Jeff Byers:Yeah. What do you think has driven a lot of that massive growth in Medicaid?
Jamila Michener:I think that Medicaid's growth has been driven by a few things. One is just need, right? Like people really do need health care. And the private market has not been able to consistently meet the healthcare needs of people who are not able to operate in that market because they don't have resources. And so need is high.
Jamila Michener:But another thing is that there are a lot of interest involved with Medicaid. And by interest, I mean groups who have a stake in the resources that Medicaid will produce for them, right? Health insurance companies, hospitals, physician groups, so on and so forth. And I'm not saying that all of these folks are like evil profiteers getting rich off of Medicaid. There are certainly people who are just to be clear organizations, corporations who are.
Jamila Michener:There's also a set of nonprofits and a set of healthcare providers and so on and so forth that are well meaning and they're doing good work, but they rely on Medicaid for their existence and thriving and for their ability to earn an income and so forth. And so all of these interests, they lobby, they exercise political power. And because they've been able to have voice and influence in our political system, they've kept Medicaid growing, expanding afloat. That's still not the people who have Medicaid, who rely on it, who need it having power. But the answer to why Medicaid has grown in part is power.
Jeff Byers:So you talk about voices kind of framing Medicaid. You talk about how people are resistant to politicize it even though it may or may not be happening among certain people. You know, as someone that works in publishing in the media, and I also used to be a poli sci major at James Madison University. Go Dukes. So I do find this, like, idea of framing and messaging pretty fascinating.
Jeff Byers:I can't remember if it was in your piece or as we were discussing an email, how a narrative helps shape the reality of either a piece of policy or a program. So how does framing a messaging affect political power in your view, especially in terms of Medicaid?
Jamila Michener:Jeff, I love that you were a poly sci major. I didn't know that, but I very much enjoy it. And this is so important. My take on framing and messaging is that framing and messaging aren't everything. Right?
Jamila Michener:I always tell people it's not as though you just tweak the word in the message and everything changes. Right? But they are something and they do matter because there is such a thing as discursive or cultural power. Right? So from the level of an individual or a group, power is about the ability to affect the circumstances shaping your life.
Jamila Michener:But your ability to do that is not only a function of what you're capable of doing or how you navigate the political system, right? It's also a function of the larger context that you're embedded in. And all of our context have floors, things that are basics that we can always rely on, and ceilings like, oh, it's really hard to get past this, you know, and all kinds of constraints. And I think that messaging and narrative can shape those contours, you know, the the kind of feeling that we can't get past the constraint that limits us from thinking about a new set of possibilities. So for example, work reporting requirements or an a Medicaid policy that just keep coming back.
Jamila Michener:Right? And even though we don't really have empirical evidence that they're effective, they don't make people work more, they don't improve health care or access to health care in any way, They don't save money. It's not really clear what work reporting requirements accomplish at all. But what they do is they feed into a larger narrative that's part of our kind of political culture in The US. This narrative of you don't get something for nothing.
Jamila Michener:Everybody has to work hard. Middle class people, are they gonna pay taxes so that these low income people can sit around playing video games on their mom's couches and get free health care? My health care is not free. I have to pay for it. Right?
Jamila Michener:Any of us, if you ask somebody, give me some narratives around why we would wanna have work reporting requirements, they could pull those up pretty quickly because that is part of our narrative context. It's the narrative soup we swim in And when and if you wanna exercise as a Medicaid beneficiary, I will say this, I engage with, talk to, interview as a part of my research Medicaid beneficiaries all the time. And if they told you about the experience of navigating work reporting requirements, it would be really clear this is making people's lives harder. It's making people's lives worse, not better. But if you ask them why are work reporting requirements bad or harmful?
Jamila Michener:They could tell you about their personal experiences. They don't readily have a narrative to pull on that's as accessible as the narrative about, hey, hard work. Everybody should work. You don't get something for nothing, so on and so forth. And so which narratives are accessible and which aren't shape our sense of which policies are sensible or are possible.
Jamila Michener:And that shapes the horizon of what we think we can even ask for or fight for in a political system or context. So narratives do matter. They're not everything. You can have an a favorable narrative, but if you don't have the other configurations of power in place to make sure that narrative translates to action or policy, it doesn't magically create change. But outside of the context of a powerful narrative that makes sense to people and that helps them make sense of their world, it can sometimes be really difficult to either build power because you can't get people on board or to exercise the power because you can't motivate people to do some of the things or get on board with some of the things they would need to get on board with to see transformational change.
Jeff Byers:Yeah. And it's also there's not really a consolidated voice for all Medicare beneficiaries. So with that, I want you, the listener, and you, Jamila, to bear with me while I ask this next question. You wrote, if we continue on the top down elite driven path that has largely characterized the first sixty years of Medicaid, the program is likely to flounder and weaken going forward. Alternatively, if we take steps to reconfigure the power relations undergirding Medicaid by investing resources into strengthening the voice and influence of Medicaid beneficiaries, and the future holds promise for a transformed Medicaid program that can do even more to meet the health needs of Americans in the next sixty years.
Jeff Byers:Again, check out the forefront article. But what in your view does that change and strengthening actually look like to influence political power's impact on Medicaid?
Jamila Michener:I think it links back to this idea that when you think about Medicaid beneficiaries or people who receive Medicaid, you don't actually think about them as a political constituency. They're Democrats, they're Republicans, they're rural, they're urban, they don't necessarily have a political core, right? But they have a set of shared interests, right? If Medicaid gets cut, they're losing not to the same extent or in the same ways, but there's a mutual loss that happens when they lose those benefits. So they have a set of shared interests.
Jamila Michener:Really building power among those people whose shared interests are that they will be harmed directly materially if they lose this benefit or their family members will or people in their immediate community will. The people who have the most urgent and direct stakes. For those people to have say, substantive say over what happens with Medicaid, over whether we have work reporting requirements, over whether we cut or expand the program, over what services we offer or don't offer. Do you get physical therapy? Do you get behavioral or mental health support?
Jamila Michener:Substance abuse treatment count or get covered? Who's making these decisions? And right now the answer is not the people who are gonna have to live with those decisions. And I'm talking about a paradigm shift where the people who will have to live with decisions, who will feel either the harm or the benefit of the decisions are having a real substantive say and influence over the nature of those decisions. And that is a paradigm change because it isn't the way that it's been before and it goes back to this idea of nothing about us without us.
Jamila Michener:The idea that we can make policy that's going to help low income people, people with chronic illnesses, people with disabilities, the people who rely most on Medicaid without their involvement or input or feedback or insight at all is actually on its face not sensible. And so the idea is that's what we've been doing for this first sixty years. We've been making policy about Medicaid beneficiaries. We've been doing it without them. And the idea is if for the next sixty years we change that, I think we'll see something very different than what we've seen thus far.
Jamila Michener:And I love Medicaid. I love what it's been, what it's done for so many people. But I love even more what it could be. And I don't think we see that unless we involve the people who are most affected.
Jeff Byers:So I gotta ask because entrenched power doesn't love to give up its power. You know, how likely is this change to happen?
Jamila Michener:I mean, on the one hand, we can think of it as being unlikely. You're right. Power gets entrenched and reinforced, it's hard to give up. This is why often when I talk about building power, I also talk about breaking power. People think that sounds aggressive, but there are people who have power right now and they don't wanna see the kinds of changes that are gonna enrich Medicaid beneficiaries lives and health.
Jamila Michener:They don't wanna see those happen because they can't profit from those things or they can't benefit from those things. So we'd have to break their power. I won't pretend that it's easy. I I think it's a high bar, but I will say this, it's possible. There are folks out there I think about an organization called Community Change and they're starting a Medicaid union and other organizations talking now actively about how to grow and strengthen the power of people who have Medicaid in ways that I I wasn't seeing a decade ago when I started or a dozen years ago when I started doing this work.
Jamila Michener:So I think it's a steep climb, it's a hard climb, but I actually think we're better positioned for this now than than we when we have been ever.
Jeff Byers:Yeah. Well, that's a nice segue as we wrap up. You wrote a book in 2018 called fragmented democracy, Medicaid, federalism, and unequal politics. I think that's the last word. My apologies if I, I admit I haven't read the book, so my apologies again.
Jeff Byers:It's been, you know, seven. If I we're doing eight years, eight almost seven, eight years. It's over five years, under ten years since you published the book. And I wanted to ask you, is there anything that's like any observations in the book that you think needs an update that you would share with us today?
Jamila Michener:Yeah. Well, you know, I love that we've been having this conversation about power because I actually think that is the full circle that I didn't make in the book. So in the book, I really looked at how people's experiences with Medicaid could cause them to become politically alienated and not want to engage politics because for many people, what happens to them on Medicaid is the biggest representation of the government in their lives. So if they have negative experiences with that, then why do they want to engage the government on any level? And so we call this in political science policy feedback.
Jamila Michener:You experience a policy and that policy actually makes you behave differently as a citizen, denizen, a member of a political community. It demobilizes you politically. It can mobilize you too, right? Medicare, social security, policies that are easy to get, universal, treat people well, that'll get people into politics. Medicaid policies that are sometimes challenging, it'll demobilize people.
Jamila Michener:In the book, I talked about how that looks different ways in different places. If you're in a place where your Medicaid program is stingy and difficult, you're gonna be demobilized. If you're in a place where it's generous and easy to access and low administrative burden, you might be mobilized. And I really think about what are the political dynamics that that Medicaid could be catalyzing in the book that I never quite connect that to power. Right?
Jamila Michener:And to say, okay, not Medicaid affects who has power and how much they have. And then the circle back is like that then affects Medicaid. Right? So that full feedback cycle, I think in the book, I focus more on one aspect of that and not on the other. And so this piece in health affairs and this kind of conversation we're having, I think represents my fuller circle thinking as it's developed in the years that followed the book.
Jamila Michener:It's not just about policy experiences, but it's about how and if we can build power among the people who have those experiences.
Jeff Byers:Well, it sounds like, the time is ripe for an updated edition. With that, is there anything else that you wanna point listeners to that you're working on or anything at all?
Jamila Michener:Yeah. I continue to work on these issues around around power and Medicaid. And so I would also just point folks to I've been working on a lot of doing a lot of work around political economy and Medicaid. And so I guess what I would say is whenever we're thinking about power, it's important to think about who benefits, who's harmed. Some of that is following the money, following the profit, but also following the stakes and thinking about based on the stakes who should be at the table, who isn't.
Jamila Michener:And also thinking who has a lot of seats at the table, who maybe doesn't exactly have the motives and incentives we might like to see. So just some ways to think about how do we assess this landscape, you know.
Jeff Byers:Okay. Well, fantastic. Jameela Michener, thank you for joining us today on Health Affairs This Week. And to you, the listener, if you enjoyed this episode, send it to the survivor enthusiast in your life, and we will see you next week. Take care.