Medicaid is the nation’s primary source of health insurance for low-income people. The program has saved millions of lives, but it fails to fully realize its original promise of providing poor Americans across the nation with access to quality health care. Although we often talk about it as if it were a single social program, Medicaid is actually a constellation of discrete state programs, funded with federal money.

Because the federal government only standardizes state social Medicaid policies to a limited extent, some state programs are far more threadbare than others. As a result, a Medicaid enrollee in Georgia, for instance, might have diminished access to care simply because of where they live, and many beneficiaries are compelled to navigate under-resourced bureaucracies to claim their benefits, often to discover that the care they need isn’t covered in their state.

Jacobin staff writer Meagan Day spoke to Jamila Michener, author of Fragmented Democracy: Medicaid, Federalism and Unequal Politics about why geographic health inequality persists.

MD: What are some of the ways that Medicaid programs differ from state to state?

JM: There are some health services that the federal government says are basics, which must be covered by Medicaid. Over and above that, there is an array of “optional benefits.” But the floor is very low, and optional benefits may not be things that we would call optional — like hospice care, for example.

So because of this low floor there is endless variation in the Medicaid services we encounter on the state level. Whether or not you can get a hearing aid, physical therapy, dental services — many of these are determined by the state you live in. I’ve met Medicaid beneficiaries who talked about having teeth removal covered, but not dentures, so they’re left without teeth. And it wouldn’t necessarily be like that if they lived somewhere else.

Medicaid beneficiaries often need transportation to hospitals or doctors, especially people who live in rural areas and people who have challenges due to disability. Medicaid sometimes covers this transportation, but those services also vary state to state. So we see that everything from getting to your health care professional to what services they can offer you is dependent on where you live.

MD: In your book you point out that the heterogeneity in Medicaid doesn’t just end at the state level. Where else do we see variation?

JM: I’m not the first scholar to point out that states don’t just have relationships with the federal government, they also have relationships with subnational entities, with counties and cities. States have a lot of discretion in terms of designing Medicaid, deciding certain eligibility criteria, and deciding the nature of optional benefits that will be covered. But counties and municipalities are the ones tasked with administering Medicaid. And that’s very different from policy design. Administration is about processing people, getting all of their information, deciding who’s eligible and who’s not eligible, deciding what to do when a beneficiary believes they haven’t gotten something they should’ve gotten.

So there’s this whole other realm of administration, and that happens at a level below states. Counties can be really good at it, for example if they’re well-staffed and they have enough people to interface with Medicaid beneficiaries in a way that’s humane, that recognizes their needs and their dignity. But in many counties that doesn’t happen. Medicaid beneficiaries often have problems or challenges — maybe they aren’t able to access the services they’re supposed to receive, or they have encounters with their health care practitioners that are contrary to the goals of the Medicaid program. At the county level, beneficiaries encounter a lot of variability in terms of whether they can get help and find redress.

MD: You go even further down the chain and talk about neighborhoods in the book. But neighborhoods don’t design or administer Medicaid, so how do they factor in?

JM: What’s happening on the local level is very important, and it’s not something I realized when I went into this project. But I started to ask people about their experience with Medicaid, and they started talking about their neighborhoods. It took some time for me to understand that, even though academics like to separate things neatly in our minds, it’s not that simple on the ground.

Place determines everything about Medicaid, including policy and administration as I’ve just explained, but also the constraints under which people utilize the services that Medicaid has to offer them. For instance, maybe you live in a neighborhood where the main place you go to get treatment is a clinic, and to get to that clinic you have to navigate a dangerous neighborhood, and when you get there the building itself is falling apart, and everyone you know has stories about what they’ve encountered and experienced in that clinic, and it determines how often and under what circumstances you seek care. Some beneficiaries have access to hospitals and doctor’s offices that are updated and feel secure, and some people experience health systems that are a reflection of larger geographical and social inequalities.

So from the perspective of beneficiaries themselves, Medicaid is not just about the federal government and the state government. It’s about your county, your neighborhood, right down to the block the clinic is on.

MD: Conservatives and many liberals might shrug the geographical inequality of Medicaid off as natural, as in “Of course poorer places have worse services.” But you argue it’s a product of political choices about resource allocation. How are politicians contributing to the extreme discrepancies in Medicaid services?

JM: Even if we pour a ton of money into Medicaid and health care generally, the other ways we’re expending resources in society determine how well that investment pays off. For instance, when we allow economic inequality to spiral out of control and living conditions to deteriorate, the resources we devote to Medicaid are going to be less effective. States make decisions about place-based funding all the time. If they leave certain communities and neighborhoods in the dust, the return on their investment in health care is going to suffer.

States also make decisions about counties, particularly how much of a burden for administering Medicaid they will transfer onto them. And when counties are overburdened, they respond by cutting administrative “fat” or “bloat.” Often those cuts lead to administrative processes that are much less humane to Medicaid beneficiaries. There’s always a tendency to try to avoid bloated bureaucracy and big government, but we often fail to recognize how important it is to have people with the time and energy to pay attention to Medicaid beneficiaries, to treat them with dignity, to be responsive to their challenges. States often fail to equip counties to effectively administer Medicaid, and again this leads to poorer health outcomes.

MD: Was Medicaid always this fragmented state by state, place by place, or is it getting worse?

JM: There was fragmentation from the beginning. If you look at the history of social-welfare policy in the US, you can go back to colonial times and see the seeds being sown for a very fractured, very heterogeneous social-policy system. You can see it start to happen specifically with health policy starting in the early twentieth century. And it’s not just that the seeds were sown, they were watered and grown by political choice after political choice. People now don’t question inequality in access to social benefits, because that’s just the way it is, it’s just background noise.

So it’s always been fragmented, but in the case of Medicaid as well as many different social policies, it is getting worse. That’s largely a consequence of a rightward turn in our politics over the last several decades, and of preexisting policy mechanisms that allow states to “innovate” in ways that exacerbate inequality. Federal waivers for Medicaid are a good example — they started off as a way for states to supposedly improve their health care systems, and they became a mechanisms for retrenchment when states started using the waivers to add work requirements to get people off the Medicaid rolls. Because of political choices like this, it’s getting worse even though it’s been bad for a long time.

MD: Given that federalism means that states run their affairs, to what extent can we even change this situation?

JM: Federalism isn’t going anywhere, and as long as we have it that means there’s always likely to be some variation in outcomes across the polity. But we don’t have to accept this degree of inequality. And we shouldn’t. For one thing, there are other federal polities in the world that don’t have this level of inequality, so we know it’s not inevitable. And importantly, extreme inequality leads to an erosion of democratic citizenship and a diminishment of democracy in general. This is happening to such an extent that people now have differing degrees of incorporation into the political system, which is a fundamental problem that we need to contend with.

Sometimes in this political environment it’s hard to remember that we can make choices, but we can. We have options about, for instance, what kinds of inequality we will tolerate. There is a knee-jerk acceptance of this idea that different places will get different services and see different outcomes, but as far as I can tell there is very little that can justify the depth of these differences. If you ask somebody to give you a cogent case for why people in Mississippi should have so much less than people in New York, it’s crickets. The arguments sound practical, but are they right?

Inequality is intuitive to many of us, and we’ve come to accept it. Part of what I try to do in the book is challenge us to ask ourselves if the current situation is tolerable, and if it conforms to who we say we are.

Jamila Michener is an assistant professor in the Government department at Cornell University.

Meagan Day is a East Bay DSA member and a staff writer at Jacobin.