The Exclusionary Nature of Federalist Politics in Healthcare Inequities and Policy Fragmentation

Salut, mes belles fleurs :) I recently reviewed Fragmented Democracy by Jamila Michener, a book I first encountered in my Public Policy class. Focused on the intersectional experiences of democracy among Black Americans, Michener’s work feels especially relevant in today’s climate of rollbacks and weakening of programs that support Black Americans and other marginalized groups. For example, we are seeing the elimination and stigmatization of diversity, equity, inclusion, and accessibility (DEIA) initiatives, the scaling back of environmental justice tools and research, and threats to grants and legislation-such as those created through the Inflation Reduction Act-that were designed to benefit these communities. Michener powerfully illustrates the downward spiral that emerges when communities come to understand that their political system is not designed to serve them.

In light of Michener’s work, one might also connect her arguments to current political pushes to cut what leaders including the current administration and figures like Elon Musk frame as “waste, fraud, and abuse.” Too often, this rhetoric translates into shrinking or undermining critical programs like Medicare, which disproportionately harms vulnerable populations.

At its core, Fragmented Democracy is not just about federalism. Michener makes clear that federalism is the mechanism through which the uneven political lives of Medicaid recipients take shape. It contributes to broader patterns of inequality and reveals how fragmented policy structures can weaken democratic participation while reproducing inequities.

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Michener used a mixed-methods design of interviews with Medicaid beneficiaries and advocates, administrative records, and large sample surveys like The Fragile Families and Child Wellbeing Study (Michener, 2018, p.75).

Her research shows that when access to Medicaid expands, more people vote, and when it contracts (or there’s a narrower scope of benefits) then people are less likely to vote (Michener, 2018, p.72).

• Key takeaways include her of the idea of Contextualized Feedback Model (Michener, 2019, p. 25).

  • 'Contextualized' says that policies are not isolated entities but very much shaped by people’s unique contexts.

  • 'Feedback' says that policies don’t just come from political action, but they also create it.

  • 'Model' says that a new way of thinking is needed to consider both aspects of public policy. 

She believes political scientists, policy makers, and policy activists along with other political actors should keep democratic consequences of federalism (or, the impacts of a fragmented democracy) in mind and prioritized when engaging in discourse and decision-making.  

These consequences arise from the systemic effects of federalism itself—for example, the freedom states have to diverge from federal policy or the fragmentation of state-level systems, which can leave certain groups vulnerable to racist, oppressive, or restrictive laws. These consequences go on to include:

• Unequal Access to Benefits

  - - Federalism means states vary widely in Medicaid access, which produces unequal political inclusion depending on where someone lives.

  
  

• Political Participation Gaps

  - – Expansions of Medicaid correlate with higher voter turnout, while restrictions or administrative burdens suppress participation.

  
  

• Weakened Collective Power

  - – Fragmented structures can make it harder for low-income groups to mobilize politically, reducing their ability to influence policy.

  
  

• Reinforced Inequality

  - – Fragmented policy structures actively reproduce inequality across race, class, and geography.

  
  

• Eroded Democratic Accountability

  - – With responsibilities divided between federal and state levels, it’s harder for citizens to know who to hold accountable, which weakens trust and engagement in democracy. This erosion deepens when people see that government or political actors do not recognize their right to health and life through adequate medical care, leading constituents to distrust both institutions and lawmakers.

  
  

Another key takeaway from the book comes from her interaction with a Medicaid beneficiary named Terrie. Terrie opened Michener’s perspective regarding deep alienation and how political exclusion made her feel powerless in democracy. She described how Medicaid in Georgia had significant limitations, such as restricted doctor availability, and contrasted that with her experiences in Ohio, where she felt the system was more responsive (Michener, 2018, p. 1-3).

From birth to death, policies like Medicaid shape not only access to care but also one's sense of inclusion in the democratic system (Michener, 2018, p. 49).

Nobody wants to participate in a democracy that constantly tells them they don’t matter or that they’re less deserving of rights and benefits than others. This helped lead to the conclusion that the program itself is not the problem, but the policy nuances and accessibility send people messages about their value with respect to the government.

As a student, Michener was never really impressed by the Federalist papers. She talks about falling asleep to them in a discussion at her job Cornell University (Cornell University Library, 2019). And I can relate to that. But after reading Fragmented Democracy and spending a semester studying public policy, I can agree with Michener. I too have found the light bulb moment in federalism. Not so much in federalism for its own sake, but in the thread that links it to everything I care about: democracy, civic participation, equity, and justice.

Michener spent years interviewing Medicaid beneficiaries and advocates. She was interested in the role government played in people’s lives and deeply wanted to understand the communities that she wanted to impact. As an Environmental Studies major, I too am interested in the way policy not just affects but relates to communities in the realm of Environmental Justice, particularly the communities I’m a part of, and others who’ve been historically excluded and oppressed. Michener’s interviews reminded me that all voices matter, and that storytelling can be political by disrupting dominant narratives and reclaiming agency. Her work gave me permission to see knowledge as a healing act and advocacy as both a structural and spiritual calling.

Her Contextualized Feedback Model parallels with my own framework of Sustainable Interconnection in a truly empowering way. Sustainable Interconnection is my framework for understanding how natural, social, and political systems are deeply intertwined in the pursuit of environmental justice. It recognizes that sustainability cannot exist in isolation; it must be integrated with equity, governance, and systemic resilience. My framework requires not just understanding systemic relationships but also bridging ethical and cultural frameworks to foster transformative and meaningful engagement and change.

While Michener’s work is rooted primarily in a socio-political context and mine is informed by environmental and spiritual philosophies like deep ecology and ecocentrism, both models share a fundamental truth: policy shapes how people see themselves, one another, and their capacity to act. Both frameworks honor the lived experience as essential to defining what justice, equity, and sustainability should truly look like. In that way, Michener didn’t just help me understand why federalism matters. She helped me understand my own power as a storyteller, scholar, and future changemaker.

Public policy is shaped by people, power, and politics and Michener wants readers to understand that policy and federalism do matter, especially when it comes to the link between political equity and health equity. Her work shows that these aren’t just academic ideas. They are living realities that shape people’s ability to access care, be heard, and feel valued by their government.

Written in 2018 by Jamila Michener, a Professor of Government at Cornell University. Available basically everywhere books are sold.

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Works Cited

Cornell University Library. (2019, December 20). Fragmented Democracy with Jamila Michener [Video]. YouTube. https://www.youtube.com/watch?v=UGCjFvb2Wj8

Michener, J. (2018). Fragmented democracy: Medicaid federalism and unequal politics. Cambridge University Press.