Building Power for Health: The Grassroots Politics of Sustaining and Strengthening Medicaid.

CONTEXT: Notwithstanding an impressive corpus charting the politics of Medicaid, we have much to learn about the contemporary politics of sustaining, expanding, and protecting the program. There is especially scant scholarly evidence on the significance and function of grassroots political actors (i.e.,the communities and groups most directly affected by health policy). This paper explores the role such groups play in the politics of Medicaid. METHODS: This research is based on qualitative interviews with organizers and advocates working in the domain of health policy. FINDINGS: The power of grassroots actors in Medicaid politics is constrained by political and structural forces including philanthropic funding practices, racism, and partisan polarization. Nevertheless, when bottom-up actors effectively exercise power, their involvement in Medicaid politics can transform policy processes and outcomes. CONCLUSION: Grassroots actors-those who are part of, represent, organize, or mobilize people most affected by Medicaid policy-can play pivotal roles within Medicaid politics. While they do not yet have sufficient political wherewithal to consistently advance transformational policy change, ongoing political processes suggest that they hold promise for being an increasingly important political force.

Racism and Health: Three Core Principles.

Policy Points Racism operates in conjunction with interlocking forms of oppression, so it must be addressed relationally. Racism catalyzes processes of cumulative disadvantage as it extends across multiple policy domains along the life course, so it necessitates multifaceted policy solutions. Racism is a function of power relations, so the redistribution of power is a necessary precursor to health equity.

Entrenching Inequity, Eroding Democracy: State Preemption of Local Housing Policy.

Housing is a fundamental right and a vital determinant of health. Health equity is not possible without widespread access to safe, affordable, high-quality housing. Local housing policy is a central conduit for advancing such ends. However, preemption of local law is a powerful institutional mechanism that state legislatures sometimes deploy to inhibit or nullify municipal efforts to address housing-based inequities. Local housing policies often have high stakes, are ideologically laden, and are politically salient. This makes them a clear target for preemptive action. Political science research to date has focused on broadly explaining the causes of preemption, with scant emphasis on its consequences and minimal attention to the implications for racial and economic equity. This article highlights the political repercussions of state preemption. Drawing on in-depth qualitative interviews, the article examines how local tenant organizations that work to build power within racially and economically marginalized communities perceive and respond to state preemption. The findings demonstrate how both the reality and the threat of state preemption prompt tenant organizations to adjust (and often minimize) their policy goals and to adapt their political strategies in ways that strain their capacity. By burdening local organizations that are crucial power resources in marginalized communities, state preemption of local housing policy risks entrenching inequity and eroding democracy.

Information From Same-Race/Ethnicity Experts Online Does Not Increase Vaccine Interest or Intention to Vaccinate.

Policy Points Mass vaccination is essential for bringing the COVID-19 pandemic to a close, yet substantial disparities remain between whites and racial and ethnic minorities within the United States. Online messaging campaigns featuring expert endorsements are a low-cost way to increase vaccine awareness among minoritized populations, yet the efficacy of same-race/ethnicity expert messaging in increasing uptake remains unknown. Our preregistered analysis of an online vaccine endorsement campaign, which randomly varied the racial/ethnic identity of the expert, revealed no evidence that information from same race/ethnicity experts affected vaccine interest or the intention to vaccinate. Our results do not rule out the possibility that other low-cost endorsement campaigns may be more effective in increasing vaccine uptake, but do suggest that public health campaigns might profitably focus on issues of access and convenience when targeting minoritized populations in the United States. CONTEXT: The COVID-19 pandemic in the United States has been unequally experienced across racial and ethnic groups. Mass vaccination is the most effective way to bring the pandemic to an end and to manage its public health consequences. But the racialization of public health delivery in the United States has produced a sizable racial/ethnic gap in vaccination rates. Closing this gap in vaccine uptake is therefore essential to ending the pandemic. METHODS: We conducted a preregistered, well-powered (N = 2,117) between-subjects survey experiment, fielded March 24 to April 5, 2021, in which participants from YouGov's online panel-including oversamples of Black (n = 471), Hispanic/Latino/a (n = 430), and Asian American (n = 319) participants-were randomly assigned to see COVID-19 vaccine information endorsed by same- or different-race/ethnicity experts or to a control condition. We then measured respondents' vaccination intentions, intention to encourage others to get vaccinated, and interest in learning more information and sharing information with others. FINDINGS: Same-race/ethnicity expert endorsements had no measurable effect on nonwhite or white respondents' willingness to get the COVID-19 vaccine, to encourage others to get the vaccine, or to learn more or share information with others. CONCLUSIONS: Our study provides empirical evidence suggesting online endorsements from same-race/ethnicity experts do not increase vaccine interest, advocacy, or uptake, though same-race/ethnicity endorsements may be effective in other venues or mediums.

The US Medicaid Program: Coverage, Financing, Reforms, and Implications for Health Equity.

Importance: Medicaid is the largest health insurance program by enrollment in the US and has an important role in financing care for eligible low-income adults, children, pregnant persons, older adults, people with disabilities, and people from racial and ethnic minority groups. Medicaid has evolved with policy reform and expansion under the Affordable Care Act and is at a crossroads in balancing its role in addressing health disparities and health inequities against fiscal and political pressures to limit spending. Objective: To describe Medicaid eligibility, enrollment, and spending and to examine areas of Medicaid policy, including managed care, payment, and delivery system reforms; Medicaid expansion; racial and ethnic health disparities; and the potential to achieve health equity. Evidence Review: Analyses of publicly available data reported from 2010 to 2022 on Medicaid enrollment and program expenditures were performed to describe the structure and financing of Medicaid and characteristics of Medicaid enrollees. A search of PubMed for peer-reviewed literature and online reports from nonprofit and government organizations was conducted between August 1, 2021, and February 1, 2022, to review evidence on Medicaid managed care, delivery system reforms, expansion, and health disparities. Peer-reviewed articles and reports published between January 2003 and February 2022 were included. Findings: Medicaid covered approximately 80.6 million people (mean per month) in 2022 (24.2% of the US population) and accounted for an estimated $671.2 billion in health spending in 2020, representing 16.3% of US health spending. Medicaid accounted for an estimated 27.2% of total state spending and 7.6% of total federal expenditures in 2021. States enrolled 69.5% of Medicaid beneficiaries in managed care plans in 2019 and adopted 139 delivery system reforms from 2003 to 2019. The 38 states (and Washington, DC) that expanded Medicaid under the Affordable Care Act experienced gains in coverage, increased federal revenues, and improvements in health care access and some health outcomes. Approximately 56.4% of Medicaid beneficiaries were from racial and ethnic minority groups in 2019, and disparities in access, quality, and outcomes are common among these groups within Medicaid. Expanding Medicaid, addressing disparities within Medicaid, and having an explicit focus on equity in managed care and delivery system reforms may represent opportunities for Medicaid to advance health equity. Conclusions and Relevance: Medicaid insures a substantial portion of the US population, accounts for a significant amount of total health spending and state expenditures, and has evolved with delivery system reforms, increased managed care enrollment, and state expansions. Additional Medicaid policy reforms are needed to reduce health disparities by race and ethnicity and to help achieve equity in access, quality, and outcomes.

Race, Politics, and the Affordable Care Act.

The political processes surrounding the Affordable Care Act (ACA) offer valuable lessons about race and politics in the United States. In particular, the ACA underscores a critical tension between politics and policy in a racialized polity: even when policies are intended to target and address racial disparities, politics can undermine the steps necessary to do so. Close scrutiny of the ACA during its first decade reveals how race intersects with politics to render public policy less equitable and more vulnerable to erosion. Ultimately, this analysis points to the ways that racialized political processes are formidable barriers to equitable material outcomes. By examining such processes and making them visible, this article elucidates the possibilities, limits, and contours of public policy as a mechanism for achieving racial justice.

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

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.

Racism, Power, And Health Equity: The Case Of Tenant Organizing.

Racial disparities in health are among the most disconcerting forms of inequity in the United States. Divergent health outcomes between Americans racialized as White and those racialized as Black, Latinx, and Indigenous do not stem from biological or genetic differences. To the contrary, "race" comes to have concrete consequences through social, economic, and political systems. Yet the political contours of health equity remain especially understudied. This article places the politics of health equity in the foreground through the lens of housing, a critical determinant of health. Drawing on in-depth qualitative evidence rooted in the experiences of tenants who confront health-threatening housing conditions, I examine how people within racially and economically marginalized communities organize to build political power in response to those conditions. By charting how tenants navigate state and local political processes, I demonstrate the possibilities for organized tenants to wield power in ways that help advance health equity in the face of structural racism.

Health Justice Through the Lens of Power.

Health justice is an aspirational north star for scholars, practitioners, and anyone who refuses to accept the status quo of profound inequity. But what does health justice mean? How ought we conceptualize it? There is no correct answer to these questions, but any robust rendering of health justice must account for power and politics. This article posits that the path to health justice requires political struggle taking (at least) two forms: (1) building power and (2) breaking power. Building power for health justice means cultivating the political capacity of people who are disproportionately harmed by health inequity, and who therefore have the most at stake. Breaking power involves weakening and destabilizing the economic and political forces that perpetuate health inequity. By surfacing and elaborating these crucial modes of political struggle, this article points to a way forward for achieving health justice.