 I'm Mark Schmidt I run the political reform program here and we're really thrilled to I'm just gonna welcome you all to this wonderful discussion of the book Fragmented Democracy by Jamila Michener who's a professor at Cornell and I think one reason we were interested in doing this event and doing it together with the Family-Centered Social Policy Program at New America which actually got us started was really because we're interested in the way we talk about political reform but often conversations about political reform just go to voting rights or campaign finance or those things that we think are part of the you know the procedures of elections and legislative process and I think we sometimes neglect the way in which well obviously the process of politics leads to policy but policy and programs themselves have a profound effect on the way people feel they can be engaged as citizens the kind of power they have whether they're how they're treated and and how they feel as they as they participate in the other processes and you don't get that linkage very often so I think one of the wonderful things about this book is it's a lot about how particularly Medicaid has evolved but a lot about how programs like Medicaid shape people's experiences of government and democracy and their levels of trust and confidence so we're gonna look at this from a bunch of different directions and Rachel Black from the Family-Centered Social Policy Program will introduce the speakers but we'll start with her and Jamila. Thank you. Great thanks so much Mark and thank you Jamila for being here. I don't think we would have expected when we started having the conversation about doing this event late last year that it would be so timely. Happy accident. People always say how did you know that this was the topic that I had no idea. Yeah it's quite fresh. So I think you've been keeping up with the politics of Medicaid right. There are constant conversations about retrenchment right just connected to the overall yeah landscape of ACA then also the ever-widening net of programs that get encapsulated under the welfare banner. I think your book really helps us think about what the stakes are right for the for the decisions that are getting made and the policy choices but it also really complicates our understanding of what success looks like right because it's not just stopping retrenchment in this political moment. So talk to us a little bit about how you see the stakes of what's happening now but also how the solutions are much more deeply connected to really a very unstable foundation and that's that's gonna be more work. Yeah this is the theme of all my teaching essentially. Students always say I started off taking this class because I wanted to get solutions about poverty or about mass incarceration or about inequality and at the end I don't feel like I have any solutions I just feel like the problems are deeper and essentially that is what your question reflects and it's a theme in my life more generally and in the book in particular because you know the focus of the book on Medicaid is really helping us to think about one aspect of Medicaid that's foundational because it's not just an aspect of Medicaid it's an aspect of the sort of structure of our social policy in the US more broadly which is geographic heterogeneity federalism right and the fact that across states across localities I mean right down to neighborhoods we see really different resources that people have access to and that's the case in terms of Medicaid and a whole range of other things. The problem as I see it because I'm a political scientist so I care about political engagement and participation is that I find evidence and I demonstrate in the book that that this has implications for political engagement and participation and so the fact that people are getting such varied resources in different places correlates with the extent to which they're willing and able to engage in and political participation now if the question were just about resources then we could say that the solution is well let's just give a whole bunch of resources well there's two problems with that one is that that's not going to happen anytime in the near future and and depending on the way we the way we design health care more broadly and other systems it may or may not be sustainable although I'm a fan of giving more resources but the second problem is that the problem isn't just about the degree of resources but it's about the distribution of them and it's about the fact that the political mechanisms that determine the distribution of those resources are so closely tethered to geographic space and place and so there are places where Medicaid is a lot more generous and where people are able to access a lot more services and have many more resources and there are other places where it's the precise opposite then the the way that I sort of changed how we think about success in the book is to say that this metric this metric of equality has to be part of how we think about what success looks like for social welfare programs like Medicaid and so is it success if people in New York state can get a lot and people in Mississippi or Alabama or Florida get dramatically less I mean I'm happy that people in New York state have access to more but what does it say about our foundations and about our our sort of nation as a whole that these disparities exist and what I what we know from the book is is what not just what it says about our nation in a sort of you know a broad idealistic sense but what it does in practice is it creates chasms as far as political equality and that has sort of implications going forward right because it contributes to this perverse cycle where we're disempowering the very people who might do something about this right so it means that we have to kind of take a critical eye to systems to structures like federalism and that's more complicated right people are saying well what are you saying we need to get rid of federalism well that's not tenable not exactly and that's not exactly what I'm saying although I I would be lying if I if I said that I'm not a fan of universal healthcare because I am but it's really beyond like that and it's about thinking through the repercussions of this structure and how we can work with what we have or if need be transform what we have so that our reality comports with our ideals which right now it just doesn't I love how you bring up in the book that looking at the experience of individuals right and how they are experiencing the relationship between federalism and democracy I mean this is a metric that's been kind of outside of our calculus and if we really want to understand how we are measuring up to those ideals right of equality of democracy that this is really kind of where you have to look and so often the people who are impacted by policy are outside of that conversation and you deliberately bring that to the foreground of your analysis and your discussion in your book so bring some of those people into the room and help us understand kind of what your education was and kind of approaching the subject how that changed and how you want us how you want your book to be a vehicle vehicle for shaping how we understand the relationship between federalism and democracy that's great I love it when people ask me to talk about people because I always find that much more interesting than most of the things that I talk about most of the time I was thinking about having slides and just having the slides be like quotes from my interviews right sort of bringing the people into them I was worried though that that would be so much more interesting than anything we were saying and that we would like lose the entire audience so selfishly I decided not to do that but you know one of the things I always tell people is worth noting is that there are entire categories of challenges to our democracy and to our politics that we will not perceive if we don't insist on engaging and talking to people outside of the bubbles that we live within so I mean I I actually grew up my parents are immigrants and I grew up in low income neighborhoods in New York City so I haven't always been in a bubble but at some point I started going to graduate school and I started mostly being around people who were highly educated and who were from a limited number of backgrounds and when I was in graduate school and I started to think about what I wanted to write my dissertation on I knew I'm you know I'm not a one-trick pony but I only have a few tricks so there's just a couple things that I really care about and that I've always really cared about and poverty and racial inequality and public policy are basically those things right and political engagement and so I knew I want something in this realm but in order to zero down on what that something was I didn't want to go and like go to the literature and read a whole bunch of books and figure out where's there a gap in the literature I think I'll go there that just wasn't a compelling mode of kind of identifying what mattered and so my dissertation advisors although they were worried allowed me to sort of have some freedom and I started doing interviews just talking to people unemployed people on the South and West sides of Chicago I was at the University of Chicago it was convenient and there were plenty of poor people around so it was also relevant and I wanted to see what mattered to people in their lives and I asked these ridiculously open-ended questions like some of these my advisor suggested so you know it's on them one was what do you think about the American dream right things like that like well what do you think the biggest what are the biggest ways that like government and policy affect your life and people started bringing up health care a lot and I didn't bring it up because it was literally not on my mind and and I realized if the point of the exercise was for me to identify an area that mattered for people I identified one and so one of the early with people that I interviewed I call her Mabel in the book everybody has pseudonyms and Mabel you know I asked her this question what do you think about the American dream and she said what American dream as a nightmare and she went on to tell me about having to choose between paying for her diabetes medication and paying for her food and I said well what about Medicaid and she said well I was on Medicaid for a little while but it was so demeaning and it was so you know just unbearable that I stopped like I never re certified I never re-enrolled and I was like that's crazy you have diabetes you need medication like how demeaning could it be that you're risking your life and and she went on to tell me and she had this interesting story but it was all about place she had moved at some point to the suburbs outside of Chicago and you know it was during a time when her fan her son was doing well economically and he moved to the suburbs and sort of brought her out there with her with him and that was when she first was unemployed and she so her first experience with medic Medicaid was in the suburbs of Chicago Naperville or something like that and it was nice it was a pleasant positive experience she's like I didn't even know I was going into a Medicaid office it was just in a bank building right and everyone was nice and I got immediate service and it was great but then her son lost his job and they had to move back to the city and she went into the Medicaid office the first time she had to re-enroll she's waiting on a line that's around the corner on a block that's really dangerous she's looking at the litter on the ground she's looking at the building crumbling she goes in there the service is back and after enough of that she just decided I don't even know if this is worth having this healthcare and that was the first inclination to me that like a this matters to people and b it's really about place in ways I hadn't imagined and the more people I talked to the more I was told that right one of the first people I interviewed when I moved to Michigan and I started a postdoc at the University of Michigan was a man who I call him John in the book and I was really curious to hear from like honestly I'll be completely straightforward from some white people because when I was in Chicago I was mostly interviewing black and Latino folks and it actually been difficult for me to recruit white people because a lot of the recruiting I was doing at first was face-to-face and like the white people just said no they just didn't want to talk to me about that topic and I don't like sort of presume to know motives I think it was just it didn't seem like a conversation they were interested in having so when I got to Michigan I recruited in some different ways so that people didn't see me initially and I got some interviews so I'm interviewing this guy named John and he seems like a kind of middle-class white guy and it turns out he had a kind of chronic debilitating disease that prevented him from being able to work he had had it since he was a child had been on Medicaid since he was a child and had all of these experiences but at some and he told me a ton I mean it was like two-hour conversation but at some point he told me about wanting to move to Arizona because his family was moving to Arizona the weather was better for his doctor said you'll do better there the weather is actually good for your his his condition involves some issues with his lungs and the cold air was a problem and there were all these reasons he wanted to move to Arizona and he started doing research about Arizona's Medicaid program which if it's instructive is called the Arizona health care cost containment system Medicaid is not even in the title I couldn't make that up right it wouldn't it wouldn't be as interesting if I made it up and as he did his research he was able to talk to people he knew in Arizona because there are these kind of communities of people in different states who had this chronic illness and he was able to talk to people in Arizona who have that illness and they were like no way you shouldn't come here like you won't be able to get you know they told him all of the different services and benefits he wouldn't be able to get he said some of these things like my life is going to be in danger if I don't get them I can't move there and so he watched some of his family moved to Arizona and people were able to move on with their lives and they weren't and he just said to me I don't understand why we can't have one program and I just had a conversation after conversation with Medicaid benefits series without me prompt because remember at the beginning I didn't know this was what I was doing I didn't know I was gonna write a book that was about federalism and Medicaid and it wasn't until I went back and I started listening through all these conversations and realized people keep invoking place either on the state level on the local level that is a huge part of the story so to say that like well bringing people's voices in is important it I wouldn't even have realized that this was something that mattered as deeply as it did unless I was talking to people that's just not something I was gonna pluck out of my head although I was fully aware that Medicaid was an intergovernmental program and it was heterogeneous across states but that translating into a concrete understanding of what that meant for people's experiences for their lives for their political engagement that only happened by being willing to engage those people yeah and I think something else that really comes through is just how clarifying it is right things like why isn't there just one program yeah why isn't there just one program I was like you know I could tell you a long story about US history of your social policy and health policy but I can't really answer that right now yeah but that being the general takeaway from one's analysis of one's own experience right I remember talking to a mom in Jackson Mississippi about her experience navigating TANF and SNAP and she said I don't know why they make it such a hassle if people need help why don't you just give it to them it's like why don't you just give it to them I mean exactly right in ways that when we're approaching it from a more policy or politics kind of orientation right I think it kind of there's some white noise that happens you know and we kind of trip over trip over our own analysis I'm glad that you mentioned the kind of Orwellian name of Arizona's Medicaid plan because I wanted to share a quote from Terry that I think kind of it is a really kind of incisive observation about how these programs work Terry's and this is a woman who has experienced Medicaid and multiple states some positive experiences some negative and this is you know her observation about that and if it was up it excuse me if it was about helping people you would say yes let my state be more productive and healthy so that we do not have to have people losing their lives and so that they can be productive citizens and I think what really grabs my attention about that statement is like its conditionality right if it was about helping people it is not a foregone conclusion that these programs that are set up with the ostensial goals of supporting people's access to quality health or to food or to cash are designed in ways which allow them to execute that goal and it is perceived by people who are navigating these systems that that is in fact the case so their role being is being held in tension with some other priority right and that priority is winning out so if it's not about helping people what is it about yeah this is interesting so last week I was in or maybe it was it was the week before that I was in Tampa at this event that like a health care collaborative had invited me to and they were like we really want to get a sense of like our consumers right medicaid beneficiaries because they think of they sort of call them consumers and his language of consumers and we want to know how to sort of get them more engaged and what we can do or what we might be doing wrong so I'm talking in this room I mean there were probably 250 people in the room of of providers practitioners some policy folks and one of the things that really stood up in that conversation was so I gave a talk I talked about the book and afterwards someone came up to me who worked for a health care provider and said you know these things are not happening by accident right you know that like the fact that experiences with medicaid are causing people to be in disengaged from government and causing people to like utilize the program less and utilize the benefits less like you know that's on purpose right he's like and I know this from the from a perspective of like the provider and the things there are people who we want to stop coming to the office and you know I don't know how politicians think but I would imagine there are people who they don't want going to the polls and he's like what do you have to say about this not this being the way the programs are designed to work right and I thought nothing really because that's deeply profoundly depressing but of but of course right there's there's some and I think there's there's probably heterogeneity in that too right I think there are places and there are people who very much want these programs to serve the purposes that we imagine for them to provide people with more security with with more well-being to take care of folks and then there are those that don't and so those goals are in tension and the the part that you just brought up that was crucial for me was realizing that that tension is apparent to the beneficiaries it's easy for us to imagine like one of the questions I would ask people in my interviews is well how do you imagine a Medicaid the average Medicaid beneficiary in your mind and I was always astonished that people like usually said something negative even though these were Medicaid beneficiaries that I was talking to but they imagine that the average beneficiary was someone not like them someone who was like just trying to live off the government or on the dole or not working hard enough or what have you and they weren't like that and they went to lengths to explain why but they imagined this other thing and I think that you know whoever it is that we imagine that we're helping there's a variation in that there's variation the extent to which we think that a program like Medicaid is the way to do it and the extent to which we're willing to sacrifice resources in order to do it I I was on this radio show earlier today actually it's like called in and it's I don't know what the thing is my producer said this person from my publisher said this person from a radio show wants to talk to you and he kept asking me questions about like what about the taxpayer you know what about the fact this is really expensive for the taxpayer should the taxpayer want to put their money into this program and there are all sorts of arguments about like why actually in the mid and long term this is perfectly sensible from the perspective of the taxpayer and so I went into that but I kept thinking I wish you could talk to some Medicaid beneficiaries I wish you could understand people's experiences and could understand the way that navigating this institution shapes their lives and their taxpayers in different ways and even if they're not there are fellow citizens and that might sound cheesy but but it's also true and they matter and I just wish we could shift the conversation in a way that centered the extent to which these are people they're human beings who have dignity who matter and it doesn't have to be this way but it is and it is by design and I try to emphasize that in the book this isn't happening accidentally I don't know the extent to which people have nefarious motives in their head and I try to sort of assume the best and I also don't necessarily care about what's in people's hearts and minds what I care about is what policy is pervading and what policy is pervading as far as Medicaid is is is a particular kind of inequality that's rooted in the very you know political institutions that we built in this country over a long time but that has really concrete meaning for people I always say to people you know I know when you hear the word federalism your eyes glaze over right but stay with me because this one actually matters for real people I think you talked about you know public support kind of being framed around an image of who they presume right the beneficiary to be and the challenge of reframing against that presumption and think that's made even more challenging when that presumption is actually codified into the policy choices and we're seeing these choices being adopted more and more even within Medicaid which has historically been understood to be a health care program and not a traditional welfare program but is trending towards adopting things like work requirements things that you see in TANF something that's usually a distinction of being a more traditional welfare program which inherently communicates that people will not work unless coerced right and that they are that they're lazy and trying to take advantage of the taxpayer right and this also comes across in other things like drug tests which communicate that you are criminal that you're definitely trying to fleece a program or any number of other kinds of of any other policies that are not rooted in any kind of evidence that they are necessary that people who access these programs are categorically different than anybody else but they are very effective at branding those beneficiaries right in creating stigma and so many of those are just rooted in a presumption of a beneficiaries race you know identity is just so deeply connected to those design choices and I think the recent experience of Michigan right and everyone knows I've been ranting about this for a while you just had a new piece published today in polyarchy I encourage all of you to as a rant how it all began and the passion comes through so talk us talk us through that because race was decisive right and how they were choosing to how they were proposing to implement the adoption of work requirements in the state and there are other states so so Michigan has has pulled back on this and there are other states that are still that still have a similar plan right like Ohio and so essentially Michigan said okay we're going to have work requirements one of the things I talk about in the piece is work requirements in and of themselves have racial implications right people of color are more likely to have criminal records they're more likely to be discriminated against in the low-wage employment market they're more likely to live in areas where they have challenges with transportation that get them to work work is harder there's there are higher barriers to work for African-Americans and Latinos that is just impossible to argue with I would say from the vantage point of the social scientific record and so when we say then that work is going to be a condition for a program what we have to acknowledge that that has racially disparate effects even if there are no other design elements to that policy that that implicate race right so I actually think work requirements in and of themselves are racialized right but Michigan went a step further and said okay but we're going to have exemptions for people who live in counties that have high unemployment rates not people who live in cities that have high unemployment rates and the high unemployment counties are the rural counties where lots of white folks live the high unemployment cities are Detroit Flint places where lots of black people live right now the reasoning according to the sponsors of the bills or if you're in the same county you can you can get to the job right well yeah not if the transportation infrastructure is bad not if you're being discriminated against because there are other people in the county who those jobs can be given to who don't happen to be black so that you know on its face but kind of this doesn't have anything to do with race this is about the fact that it's actually easier for you to I mean I don't again I don't know what is in anybody's heart and mind and I don't presume to know nor do I want to but both sort of in terms of impact and in terms of sort of the obvious design a policy like that is going to have racially disproportionate effects I mean the piece I made in the sort of in the polyarchy or the point I made in the polyarchy piece is that we should not be surprised by that so the fact that Michigan gets flak for this and then walks it back right but the sponsor of the bill says but we didn't walk it back because of race because race didn't have anything to do with it in the first place we walked it back because administratively this would be a nightmare but then you you probably walked it back because you got a lot of flak that was based on race but the fact that he could claim that like saying race had anything to do with this is ridiculous and I think that that was an actual quote ridiculous you could only claim that if you assume sort of gross negligence of the nature of American health care and health policy right if you pretend like if from the very beginning what from whatever point we started to have anything that looked like health policy in this country it has been racialized and designed at first explicitly and maybe arguably now less explicitly although that's arguably in ways that we're going to disproportionately affect racial minorities if you pretend that that history and contemporary the reality is not doesn't exist then you could say race race doesn't have anything to do with it um but if you know about that how one can sort of in in truth say that that their the racial implications aren't clear I don't know and and that connects to a lot of different aspects of social policy Medicaid and other policies where they're sort of deeply rooted in ideas we have about who's going to benefit who's deserving who's not and embedded in those ideas are are racist and classist perspectives that so long as we can sort of distance ourselves from them and and and say that that's not our motivation we don't really have to reckon with the the scale and extent of change that has to be made in order to achieve anything that even approximates equity so I wrote the piece yeah it started as a rant because I just thought how could you how could you do this and act like it doesn't have anything to do with race um but you know it has to be much more than a rant for us to see the the degree of of policy change that we're going to need and oftentimes racist sort of siloed like we're now more comfortable talking about race in terms of cash assistance because people have been doing it for so long and there are books like why americans hate welfare and the answer is like because of race um and we've and we've been thinking about those things for long enough that were like oh okay race and like welfare you know technical welfare cash assistance those things are connected well it's it's much harder to acknowledge that that is the case in in nearly every now I would say in every right area of social policy that we cannot silo race but we have to confront it across the board and that feels a little overwhelming I mean my students you know I taught a public policy class this semester and when we started talking about race and public policy I had a student came to office hours and said this is overwhelming if it's in everything how are we gonna fix it and and maybe maybe it's just because you see race everywhere because there's something about you and that's a much more comforting thought right you people are just so paranoid our victim mongering um much more comfortable to think that than to think we need to imagine profound change in order to get to a place of equity I I admit I'm intimidated by that so something else that siloing race from the conversation does is make it seem that it's just about bias right it's about individual relationships yeah absolutely and kind of ignores um the structural mechanisms that we have for I mean effectively weaponizing that bias right for codifying that bias into policy and I think something that you lay out very clearly is the way that federalism has functioned in that way right I think that you're very measured in your assessment of um it's not a wholesale indictment of federalism uh you describe in ways that kind of remind me of like chicken I mean it just kind of absorbs the flavor of whatever you're cooking with and we just I'm gonna use that in the future um feel free um and it just so happens like the flavor that we're cooking with is racism um for like ever and it had been for ever uh and it is you cannot look at the history of anti-poverty policy right being implemented through a federalist structure without seeing federalism act as a mechanism of racial exclusion and social control right you see that you have these punitive and paternalistic policies show up basically wherever black people are you know in the south right after what was the precursor to to TANF was started um work requirements and benefits were aligned with the harvest season right um you don't see work requirements in TANF in northern states until the great migration when black mothers start moving north and that's still I mean visible today states like Oregon who have almost an entirely white population um have much more generous benefits and less restrictions on access than places like Mississippi for example um so I think looking at where there's continuity right what the interstitial tissue is it isn't as though these patterns are independently generating in silos you know there's something there's some kind of mechanism um that's connecting them together and enabling right um the absorption of racism into the chicken apparatus so my question for you knowing what we do about how federalism functions in this way um wouldn't it make sense for us to have something that we're less susceptible to absorbing those flavors and um better was better aligned for actually executing the policy goals that we set forth yeah so there are two ways I think about this question like one is the part of me that wants to say something that seems pragmatic and realistic and attainable and this is when you said well your approach to federalism in the book is measured this is because enough people who read it and said well the the takeaway from the book can't be that federalism sucks right I mean nobody well it's not going anywhere and that's not really very helpful and so I tried to think about well what are the what are some of the other takeaways but you know so there's the kind of pragmatic assuming the system is is going to be around for a while how can we think about how we might make it better maybe on the margins maybe a little bit further in than the margins um and then there's the like real me in my heart of hearts because I don't care about what is another people's heart in minds but I know what is in mine um and that's the part of me that wants to think in a much more transformative way and so people will say to me like well you're wasting all your time thinking about Medicaid when really we just need to be focused on like Medicare for all right on universal healthcare then we won't even have any of these problems absolutely grant that to you I am there with you right because the geographic heterogeneity all of the challenges built in to Medicaid as it is presently structured and many other social welfare policies I think improves substantially if we shift to something that is centralized and federal at the same time I don't think that kind of move gets us out of the pickle unless there are a lot of other things that change with it because right now states are a useful states and localities are a useful convenient and they have a long been mechanism for transmitting racial bias through institutional means right for weaponizing federalism is a useful mechanism for weaponizing racial inequality in the way that you so aptly put now the question I would have which is a counterfactual that we just can't know is if we change things if federalism was structured differently if programs were more centralized would we just find a different mechanism for racial for weaponizing racial inequality because if there's one thing that US history has shown is that we're really good at finding really creative ways of perpetuating racial inequality even when we think we've got it we think we know when we see it we think we know how to avoid it and it pops back up again and so you know I get into these conversations with with colleagues and with students and they're like well where does this leave us right everybody has to change in a deep internal way and racism has to not no longer be a part of our political culture before we see anything be different I don't like saying that either because I like thinking about things in terms of institutions and policies and I don't want progress to be reliant on people or or even institutions no longer being racist right so I want to think about institutional mechanisms and I'm happy to see dramatic transformations to federalism I think it would be a great place to start or even thinking about how to equalize resources across states and building in policy mechanisms that do a better job of that right but at the same time I'm sort of painfully aware of the possibility that even under that kind of scenario that I imagine to be like more rather than less transformative we'll have some difficult reckoning to continue to do which is not I don't I know that's not a good answer as far as what we might want to hear and think but I think it's the truth from my vantage point. So when you're talking about you know kind of chicken or egging right the culture versus policy change there's a great line even kind of uses and stand from the beginning that's a great definitive history of racial ideas in America where and this is going to be paraphrase something like you know racial hate doesn't hasn't driven the history racist ideas in America racist policy has driven the history of racist ideas in America which I think goes back to what you were saying right about the role of institutions and how they how they are resistant to or deeply embedded with the kind of bias that we're trying to trying to root out so heads up to the rest of the panel one more question that you guys are coming up so I want to finally I'm gonna end with a quote from you oh I'm gonna quote you to you this research exposes troubling political inequalities undergirded by a federated political system that too frequently mutes the voices of economically and racially marginal populations it is no small thing then that in order to produce the findings those very voices had to be heard in that sense the methodological foundations of this work gesture towards the shift that must occur in American politics if we are to strengthen and preserve this democratic process so my final question for you before opening the conversation up is what do you think the capacity of federalism is to to adopt that methodology that invites engages is responsive to and reflects the voices of people who are marginalized under our current approach to policy making yeah so if given federalism right assuming it's there and assuming that it's largely looks the way that it looks now and that sort of social policies are taking the form that they're taking now the the hard question for me and a question that literally a reporter asked me earlier today is like well so then what are the mechanisms like what what are the mechanisms for for something actually being different and assuming we don't get universal healthcare assuming the basic contours of what we have now don't change and one of the things i said which i think always is dissatisfying to people but but is what what i will say because it's what i think i can say confidently is that when i think about mechanisms for change i don't necessarily think about specific policy mechanisms like if we i mean there are policies i like more than others for sure but i don't often think like if we do this one thing or these two things or these five things solves the problem right instead i tend to think in terms of process mechanisms right so what sorts of elements can we introduce into the political process that will perhaps help us to get to different policy outcomes that change the feedback cycles right and i probably think that way because i'm a political scientist so there's some bias there but connecting to the quote that you read the the process mechanism that i'm kind of like most obsessed with is thinking about creative ways of incorporating the voices of Medicaid beneficiaries into policy processes it's hard for most people to even oh what does that even mean right it's even hard it was hard for me early in this project to really understand what that meant too but over the last year or so i've had the benefit of going all around the country and getting to like meet with and talk to different nonprofit organizations that for whatever reason i did not imagine that this would necessarily be the case but it was such a pleasant surprise are interested in the work that i'm doing and they're always interested in the work from a very concrete vantage point like they don't want to talk about the literature they don't want to hear all about like the intellectual foundations of my work etc etc and it's it's quite refreshing um although it puts me in in sort of uncharted terrain because what they want to know is how can we think about what we can do differently and so a few weeks ago i was talking to some folks in california and they said well in 1999 you know the policy institute had this big survey of like over 2 000 Medicaid beneficiaries and we got all this information about what their experiences were and what their perspectives were and if we had more information like that we could do something about it we could figure out where there were openings for change we could imagine policy in a way that connects to what people are actually experiencing and that's if there's a place that i see like within the bounds of federalism there's room for action it's or for something maybe hopeful is that all across different states there are these different actors that are like how can we bring in the voices of medicaid beneficiaries and you know i've been talking to community groups that are literally like we know what we're gonna do we're gonna like add an intervention that we weren't doing before focused on helping to engage healthcare consumers civically and politically we're gonna actually try to create the kind of political foundations necessary for change instead of just fighting one-off policy battles no no no not this waiver no no not that waiver no no no we need to expand one-off policy battles that were sort of under-equipped to fight because not enough actual people whose lives are deeply dependent on these policies are involved right so instead of doing that we think about processes for bringing these folks in on a basis of equitability not in a way that's about tokenism and on a basis that allows what they teach us to actually change our direction like the medicaid beneficiaries that i talked to actually change the direction of this book and made it what it is and do we have even as like activists or policy folks or policy wonks or advocates or what have have you do we have processes such that the people that we imagine we're acting on behalf of have an opportunity to shape the direction that we go in and a lot of the organizations that i interviewed for the book i would ask them something akin to that and they'd like kind of guiltily say not really there's yeah we're all about medicaid advocacy we don't really talk that much to medicaid beneficiaries we don't really know what they think or what they want or what they experience not all of the organizations but enough of them that i thought okay there's a process thing we could do here from a micro sort of organizational level to a more meso-state level and probably not now but under a different administration perhaps on a national level what are the processes for actually incorporating in a substantive way the voices of the people who are most affected by these policies if there's a direction that i would want to sort of advocate for it would probably be that as you said i mean that's a methodology not just for use within policymaking it's also valuable within the context of our own work we should be imagining people were working on behalf of we should be engaging them thank you for giving us such a strong model for doing that in your work and i'm gonna invite the rest of our panel to come on up i always tell students it's it's only interesting hearing me talk for but so long and you all we've already passed that mark so it's really nice for other people to join so i'm gonna start with parry so thank you all so much for joining the conversation it's really an amazing group of folks who really come at this issue from a bunch of different angles parry bacon juniors with 538 is also a previous new america national fellow and parry you have been following aca for a while both as a journalist kind of looking at it on the ground but also as a political observer right you're seeing it from both vantage points and i'm really curious to hear kind of your reaction to jumila's comments and in the context of that perspective that you bring to this um so i mean i'm you know my job is to cover day-to-day politics often so i mean my first thought was we didn't use the words democrat or republican very much probably potentially up here but in the reality the whole medicaid discussion is entirely about democrat and republican and you look at the states that have expanded it's also like you know if you think about parts of japan race too you look at the states i think the 34 states have expanded medicaid 16 that haven't the 16 that haven't are you know alabama mississippi missouri you know exactly it's not just republican but republican states with lots of african-americans so i mean so i think that's the way to so that's kind of where i you know the place matters so much in part because we've sort of race and party or so tightly tied right now i mean you know i'm from katalki has a lot of time sort of following the news there and the one thing you said about the idea that if medicaid beneficiaries were more involved i guess i feel like i watched that last year medicaid beneficiaries were involved in sort of fighting the aca repeal and in kentucky i think there have been some polls like 80 of the people opposed the work requirements i'm not sure it's not clear to me that's going to make any difference you know i think i think the so that my first thought was it's not obvious to everyone i'm sure in the room but the party factor here is so important to the place vector yeah and this is a great point to bring in liana charme she's with community catalyst and you work directly with organizing people who are impacted by the policies that we're talking about in advocacy efforts around those i'm really curious i mean jamila has talked about the yeah kind of the erosion right of trust in government to do good things and act on your behalf um so how does that show up right in your efforts to engage those people in changing the policies that are marginalizing yeah and i mean i was talking i couldn't like nod my head enough like yes yes yes these are like things that come up when we talk to um our advocacy organizations that we work with on the ground to engage medicaid beneficiaries and to really kind of connect them to political life and we saw that you know first hand last year in the aca fights um with our advocacy community all across the country really kind of um coming out and showing their you know why ac the why medicaid matters to them and what it means to them and why it's important for their voices to be heard and that's sort of what community catalyst community catalyst and the program that i work for the center for consumer engagement in health innovation really fight to do is make sure that the voice is at the center of every policy you know health care policy decision that's being made because it's their voice that should help guide policy change policy behavior policy you know effectuating the type of policy we want to see in this country so um and i i had a video that i'm happy i love to show if this is the appropriate time or go for it okay my name is kassandra adams just about everyone calls me kassie five years ago i found myself at the bottom of all bodies for me the cable went the electricity went and eventually the apartment went so i found myself homeless in the street where do i go no nobody can make it out here alone i really do enjoy expressing my story because i've been told by others that just telling my story helps so many other people i'm an advocate for people that once was homeless or are still homeless we go to harris bird and we go into senators offices and as a group we do make an impact so um advocacy we is a voice a voice for the people and i wanted to show this slide because it so and i've seen this video a number of times now we just recently released it and all everybody in our staff was emotional when we saw this it's a part of a larger story about connecting health and housing and particularly for medicaid beneficiaries and i think her voice what empowered her was knowing that there was a community of people out there who wanted to advocate on her behalf and that wanted her voice to be heard on that on that behalf too so she was involved last year in the fights in pennsylvania to protect medicaid she was involved right now you know work requirements arguments that are going on in pennsylvania right now and so you know this illustrates a lot of what community catalyst does with the center for consumer engagement does and how we do it um you know one of my slides up there was about showing a system of advocacy that we like to talk about with our um with our advocates you know what's the opportunity and then what are the different capacities that we need to we need to provide for for our advocacy organizations to really get to that policy win and one of the biggest ones is grassroots organizing you know if we don't have the voice of the people as part of the conversation then you know kind of like what you said we're not really getting at what's going to be impactful for for medicaid beneficiaries in the long run and then that sort of intersects with so many different things that in our organization we come across you know from race to class to gender to ageism and all of those things sort of are you know encapsulated in one to make sure that we think about how we how we engage not just beneficiaries but then how we engage the advocacy community and how we build coalitions and how we sort of we become the power so that we can take it to Capitol Hill or all you know the state capital wherever those fights are happening. Great and this is a good place Avi for you to jump in Avi Green with Scholar Strategy Network and you and Jamila and a couple of other colleagues wrote a paper not too long ago that provides a framework for understanding civic engagement and something that was I think so revelatory in Jamila's work is the way that she lays out through the experience of medicaid beneficiaries how things that we see as just kind of bureaucratic interactions are actually political transactions right they give assistance of our own political value how responsive government is going to be to our actions and I think in the framework that you guys developed I mean you look both at and assets and deficits assessment of these factors that I think are kind of outside of what we typically think about as you know levers of of democracy so could you talk us through what some of those are? Sure and and I just want to start by saying I'm just so glad that you're throwing this it's such a pleasure one of the things I really like about working with with Jamila with Professor Michener is that you you haven't given up on dreaming big even if you're grappling with these problems which your research and lived experience shows are so enormous and so when I think about civic wealth the idea that we threw out and I think about medicaid I think about three three definitions of the word treatment right it comes comes a blot in your book right so first there's the medical treatment that we're hoping that people get but right through federalism some people are getting better treatment and some people are getting worse treatment and then I also think about what when most people think about civic engagement especially about raising civic engagement raising turnout cost per vote that sort of thing there's a whole there's a whole industry right now philanthropic and political industry that's associated with the idea of politics as experimental treatments what happens if I knock on your door to what percentage do I raise the likelihood that you're gonna vote right but medicaid is also a a political treatment it's an experiment and it can be measured as an experimental treatment basically and and that's what Jamila's work does right is look at it in that in that frame and then lastly right when we often think about treatment or when we often use the word right there's the question of how do we wish to be treated as human beings right and one of the when we talk about place right we we use it as a shorthand but what what place is in american government is it is an overlay of local culture plus local and state government policy that those things come together to form states that's I mean there's other things but that's the main stuff right and what is happening is that sometimes medicaid in some states is treating people more like people and in other states it's treating them more inhumanely and one of the things that we have to grapple with as a society is that these treatments really last because they're not being applied to just one person or to a random selection of people but they're being treated to whole populations like the black population of Mississippi and therefore there are intergenerational effects that matter I mean it's it's wrong in and of itself I you know as a as the not political scientist sitting here I just want to bring up that it is ethically wrong and just call that out I'm allowed right and then secondly right it is also even worse because it's these effects are pernicious and last over time right so the next I think challenge that I hope political scientists will think about is how do you how do you use what we know about experimentation right and about these these treatments right to think about how can we structure the equivalence of races to the top that that take federalism into account but that shift some of the incentives for some of these states and I think actually medicaid expansion is actually a positive example here because despite it all it's spread to 34 so far and it's only been going for a few years and if you look at social security which also had a discriminatory design at the beginning it did eventually expand and move to universalism so can we figure out ways that we'll take some of that same knowledge and apply it so that medicaid can start to treat more and more people like human beings and therefore lead to these positive political civic engagement feedbacks and then we'll have a nation that has more civic wealth and I think to do that and we have to change the government operations right because what we've been talking about is organizing advocating mobilizing to fill in the carveouts right so how do we switch the default so the policies that we're creating aren't generating inequality um as soon as they pass right and I think Reggie this is where you and your word come in this is the million dollar question so Reggie Gordon who's the director of Richmond Virginia's office of community wealth building this is some of the work that you're trying to undertake right you're trying to establish an office within within city government that is explicitly charged with reducing poverty and engaging a lot of the people that we that we've been talking about right now um I think Jamila's work shows how um you know through the lens of medicaid how people base policy still play out in place right and that uh since there's disproportionate exposure to policies and institutions that act in a marginalizing way that um the African American citizens in Richmond Virginia um are getting the message that you know your citizenship holds less currency right than others people than other people is reinforced over and over and over again so talk to us a little bit about your work not only kind of establishing um the office and how it's functioning but also how it's engaging um with a community of people who have been receiving that message over generations thank you Adam glad to be in the company of people who are thinking this way and trying to move these issues forward in Richmond unfortunately we have a 25 26 poverty rate we're a medium-sized city 220 thousand people and our office started to put into effect a strategy for wealth building and we have moved away from saying even using the word poverty because that end up itself we realize sort of set apart this this class of we are going to help the poor people in Richmond now as the director of the office community wealth building I found it really uncomfortable walking to a room filled with community members and saying from the government I'm here to help and you're the poor people you know so we we try have we've been intentional about having listening sessions where we invite people in or we go to the neighborhood literally on the street corners and say here's what's here's the plan how does that resonate with you we represent not only government but myriad nonprofits and agencies who think they're doing the right thing and so we're like this conduit back and forth to the community and what we have learned it brings true what you said earlier the response is anecdotally no no one's ever helped us before no one's ever listened meanwhile we have hundreds of nonprofits hundreds of agencies and the millions of dollars for decades and if the response on the street corner or in a listening session is no one's listened before we realize as this disconnect is because we have been using the research and sort of walking in and here's the program for you as opposed to beginning with okay tell us about your life and if you were to construct a program to move from where you are now to economic well-being or financial stability what would that be and we're getting some responses which are illuminating but also challenging because the system currently sort of places a greater value on those of us who have the degrees and have worked in policy that that we're the ones that should be able to to create create a the mechanisms to help people and we're trying to flip that we have ambassadors that we've trained these are people who come through our workforce program and we actually took them through similar discussions that we might have we talked about Maslow's hierarchy of need we had someone to talk about truth and racial healing and even the Maslow's discussion was not what we expected because we assumed the response would be I want to get those basic needs met first but there was a lot of discussion about self-esteem the most important thing is having a sense of self you know the food the you know the shelter yeah but if you're not respected in the community how can you move forward so I think as we continue those type type of honest and authentic conversations will make headway we have network group meetings that have a mixture of the community and the providers and ministries working on the policies that need to shift and I'm excited about what we what we're learning together and and the response has been finally you know you're listening and Richmond Virginia you're listening and we have high hopes that we can help people in other cities use the same framework we are saying to Richmond it's time to move from a charity framework to an economic well-being framework so that's not the people who need to change but it's us that that's our main epitome at this point and let me follow up on that so for you to be responsive to that requires you to be set up in a way that's flexible right for you to be iterative and actually kind of embed what you're hearing from the community in your operations that requires you to function differently then government traditionally does and I'm really curious about how you've been able to carve out the space to be able to do that with the challenges of being embedded within city government and trying to model a new approach to governance has been I think people are listening to the words that we're using although we're in city government we have a mayor that's very supportive a city council that's supportive and we talk about compassion and and what is the role of your government these are citizens in Richmond who are looking to move forward and for far too long we have expected to find them in this neighborhood that's low wealth or that school that is underperforming and how do we begin to say no we're all we all have assets and having a mayor that believes in one Richmond is a is sort of resonates not only through my office but that message is being clearly relayed to the people at large you know just people in the community. Can I so I want to that's first of all it's amazing I love just getting to hear about what you're up to and second of all I want to point out like a little bit of what may be attention but I think is more just an instructive point of difference between the sorts of things that that Abby and and Lena and Reggie are saying and and even me to a certain extent and the kind of insight that Perry brought to bear which is like how can we're not saying anything about Democrats and Republicans like there's this whole big thing that's structuring all of our politics and somehow it hasn't come up and I think that that tension is is really instructive right because what what you just said toward the end there Reggie which is actually we have a mayor that's supportive and we have it right so there are other layers of of political institutions that actually allow us to go there it actually allow us to do this right and so without those layers right had you had a mayor that was like actually no we need to get these people working and to stop blah blah blah it would be it would be difficult to even start to think about let's have listening sessions right so I just want to underscore like even though I feel like there's some distance between so I don't I don't think about the world in terms of Democrat and Republican in part because I mean in practice in many ways I do but in in sort of in in in theory or even when I'm imagining what I want the world to look like I don't and some of that is just training like as a as a professor up in front of the classroom once you start talking about Democrats and Republicans there's half of the students in the room who now hate you and have a plunge right to almost learn how to think about how to reframe things but also because that it it just makes everything so much harder and messier and part of the reason is because partisanship imposes some real constraints on whether we can do these things that we're talking about doing and or how we have to or should do them so I've been really struck by some of the I spoke at Community Catalysts Southern Health Partners meeting in and it's all the southern health policy advocates and they're dealing with a completely different context right they're like actually we're in a hostile relatively partisan context and we have to do things completely differently even in terms of the the kind of advocacy end of it they're like when we go out into the community and we're trying to get people on board with Medicaid expansion we have to be able to go to rural communities talk to people who are who are Republicans as far as they understand themselves but who are actually being hurt by the lack of expansion and try to get them on board and then we have to go to Republican legislators who represent those constituencies and try to get them to understand that like you might want to think about this even though it's completely against your partisan interests and that does introduce a layer of difficulty and challenges but it it doesn't introduce the kind of challenges that mean that this stuff about like people's voices and Medicaid participation and engagement doesn't matter it means two things a that that matters even more but we need to be savvy and thinking about how it matters and how to channel those voices so that they can break through the partisan barriers and be that it's not all that matters right so i'm i'm very much about political voice and engagement but that's not all that matters because the engagement unfolds in a context where there are political institutions and structures like parties that are tremendously important so i wanted to at least say that and try to sort of connect some of the the disconnect between sort of the way that we seem to be talking and the very pragmatic like let's get real perspective that you brought that is so crucial too so you merely just teed it up for all of you guys so anybody just feel free to step up at this point yeah i love you know there's a slide if we could pop it up well because what you just said it's after this one it sort of is what we continuously sort of talk about with partners that we work with on the ground right like it's not just it's not just about organizing consumers but it's about figuring out all the different capacities that on the ground advocates should have in order to get to that policy change in order to be able to you know get the leadership and then you know get to that so it's the policy analysis and understanding stakeholder dynamics and you know within that state within that county within that locality it's understanding you know who are how do you communicate that the messaging and that's something you know we're constantly evolving and how we message how we message different audiences so what we say to our advocacy community versus what we say to the media versus what we say to policymakers um whether it's um you know whether it's a d or an r what we say to them how we say to them it really matters and then fundamentally and what what's that on here and what conversations that we are starting and having for the past number of years and you know we've had this in the call that you spoke at was well how does this down where does race fall into how we do all of this gender right you know sexual identity how does that fall into all of this when we think about class education so each of these single capacities and then thinking about it from all those different lenses impacts how we convey our message so it just goes to that point that you made let me add this is a good this is a good map and yet it's affected of course and structured by larger laws and systems that make things difficult and they make things difficult deliberately so for example most community health centers right have many of them have embraced a voter empowerment model where they register voters when they come and that sort of thing and it's a wonderful thing to do but oftentimes tied with state or federal contracts that they get to operate are silencing clauses where they can't actually talk in detail about the health policy issues which are facing those those which pose to those community health organizations questions of survival right and they certainly can't because almost all of them are 501c3 organizations say to the recipients well you know you want to know what's going on with Medicaid expansion if you vote for candidate a they're in favor if you vote for candidate b they're opposed and that might be the single most important piece of information you could possibly give right when it comes to the political empowerment or civic empowerment of a medicated recipient right and yet you may be prohibited by law from telling them and these challenges propagate themselves through the system coming down through foundations which are often which are bound by their own set of regulations and they prefer to give to 501c3 organizations low-income community organizations want to get money so of course they go to foundations since just like going to banks you go where the money is and then of course in order to get that money oftentimes they are asked please set yourself up as a 501c3 and a self-silencing phenomenon ensues and I spent years on the other side of this doing nonpartisan voter engagement and it was super difficult right and I think that it's it's actually incredibly to the credit of community catalysts and their partners around the country that they have thought about careful ways to push this envelope that constrains their speech right to to its edges to speak as rationally as they are allowed to and as compellingly as they are allowed to but interestingly at the other ends of wealth right when confronted with a challenge on the ability of wealthy people to use their political speech they just chose to change things you know citizens united for example is all about wealthy people realizing that they could have more political speech in a certain way and going to get it and I think that we need to think about how the very rules themselves are constraining in perhaps unfair ways so do we do that by just making it more visible is that enough I think I mean a question I constantly have is is it a lack of information or is it a purposeful understanding constructed in a way that kind of suits your own needs right just really can I just answer that I promise people in most states know which parties are medicating which what isn't I think don't you this is from my reading polls and talking to people that's not a mystery there are some people who don't want to support those policies for reasons but they're not they're not really confused about I did a few bunch of Medicaid expansion stories and I went to states and people sort of knew who to blame was for you know who who decided the policy I would agree but I would also say that the act of political communication is more than just about information sometimes it's about repetition to add someone into a community and I would would actually say that that's what's so impressive about what's going on in Richmond it reminds me of you know George W. Bush talked about having creating an ownership society and I would say that like that's what you're actually doing you know by starting from the idea that people are owners and a lot of our politics doesn't allow that and can I just add to so Medicaid expansion is like the big you know pink elephant in the room and so it may be the case that like knowledge or it's certainly the case that like knowledge of the average person or the average low-income person around Medicaid expansion is much more than it is around like a lot of the other like mundane health policy and other policy issues that matter really really deeply for people's lives that they just never really connect to a particular party or a particular political official or to a politics at all right so I would say beyond them knowing whether to map it democrat as a republican is the function of like flagging for people that this is political in the first place that may be their participation or engagement could potentially even change it and so some of the work that these organizations might be doing if their political voice wasn't constrain them that way is to either bring attention to these less salient things right so things like if our state gets Medicaid managed care what is that going to mean for what happens with my disabled child right and I talked to beneficiaries who I'm a stalwart republican but once I realized once somebody told me this means that maybe my kid won't be able to get what they need to live I switched it right up and making that direct link for people and doing it in a way that's consistent I think can potentially get us past some of these policy barriers especially when it's not salient the salient stuff just like my students they just shut down like oh we're talking about ACA I know exactly what I think shut down stop thinking stop learning but when you're in areas where people are less familiar that's where you really have room to make some headway and to get them to connect in a different way and ultimately perhaps to behave politically in a different way and so Medicaid expansion is important but it's probably the hardest case for this stuff and there are many more cases that are that may be more fruitful for thinking through how these processes look on the ground one of the things I would add to that is the importance of training consumers and consumers patients beneficiaries about about the these different programs about the programs that they are on there's a story I was torn between sharing Cassie's story or Shonad's story and Shonad is a woman who who participated in a training that we did called lift up your voice and what she says in her in her video that we took is that I didn't know I had a voice before I was trained and understood what was going on you know she's about to enter into a managed care program and she had no idea she had a voice and so I think it's important to sort of get out there into the communities which is what you know our partners on the ground do and to train people to say you have a voice you should be empowered in what you're doing and that also speaks to sort of like the concept of transformational organizing transfer you know having the ability to go out to the community and train consumers on not just a particular policy area but that they stick with that organization through the long term through the different fights the policy fights that come out from and so you know those are the couple of things that you know we strive towards that it's not just that we have consumers for this one fight but how can we then ensure that you know their voices are heard throughout the different policy issues and fights that they're going to come about in the future and a lot of our organizations that we work with do that you know they have a base of people Medicaid beneficiaries Medicare beneficiaries are people who are on both Medicare and Medicaid they have a base of people that they're able to then mobilize and power and engage when these fights go about so going back to this being you know training the training piece and sort of making you know having people understand that their voice matters can go a long way and making systems change. I was in a meeting with the community group a month ago and this that very topic came up and we just let the conversation flow and it landed on this idea that they want to create we have a citizens advisory board of using the the people as the experts rather than us hosting a meeting or trying to educate on Medicaid expansion or child support came up quite a bit let them be the expert presenters and have it in in the community and we're on the periphery which I thought was a brilliant way to make it accessible because often you know you know people are being talked to by those of us who have studied it you know but but then again I mean if you you're more relatable if you've lived the experience you know how to navigate all of these systems and processes and that gives you instant credibility so it also gives that feeling of like what I have to say matters yep versus the power dynamics in a room when like well I have you know such and such degree and such and just experience so what I have to say matters more which is not always necessarily true. So let's go ahead and open it up for questions there's a microphone somewhere Christian has it so just wait till it gets to you and raise your hand and he'll bring it on over and there's a reception app after and you have to I really appreciate everybody's perspective and I just wonder I mean the old saying about you know children and poor people don't vote and that's why their interests aren't better represented and I just wondered I mean in this day of voter suppression but what do various people think about how to register voters and get them more involved. I mean you mentioned voter suppression so that's an easy place to start which is to stop making it more challenging for people but I do think I mean I think there's like straightforward answers to that and then there are like the more the kind of deeper answers and so there are many people I will say this who are not who are alienated from the political system and not even interested in voting and so no matter how easy you make registration they may not engage and and it's in part for the some of the reasons we've been talking about which is that they don't perceive the system as being there to serve them. I actually had a conversation with my brother just before the most recent election and he said I'm not voting and I was like oh gosh you're hurting my heart I'm a political scientist why did you even tell me I mean you could have just kept it to yourself right I mean the logical thing to do just you keep that button up and pretend with me no he said I'm not voting and and he just started telling me about like friends of ours from high school and how many of them had died and the neighbor up the street who you know was having a hard time and who like literally couldn't afford food and they were trying to figure out how to get that to them and all of these like really concrete issues in day-to-day life someone a few blocks away who had been shot in the head recently he even said you know I get pulled over by the cops like two times a week what am I voting for what like what what system am I interested in upholding so I think there are some really deep sort of aspects of institutional inequality that voting is almost it's it's weird even talking about voting when I go and give give talks or try to engage with different communities it feels so far away from everything that really matters and until we address some of those things that really matter it's hard to motivate people to vote at the same time unless people vote it's hard to address so it is this really difficult challenge I think there are you know there are things we can do certainly but it you know it's not to be overstated that there's I think there's an upper bound for many of those things without more fundamental change that touches people's lives in a real way can you make the case in the book right and that that we learn lessons about our political value through a range of interactions with government whether it be the police whether it be how you're treated by your caseworker and that there are you know other ways for us to engage that are kind of more proximate to what's valuable for us and the way that a lot of these systems are functioning now creates some kind of form of like the invisible disenfranchisement right and it's something that we're not paying attention to because it's it's under the radar and it's administered through state systems right it is at the hands of the police which I mean we know that you know after incidents of police brutality in black communities the rates of calling 911 goes down right I mean this is supposed to be a service that's there for the community and the people who are most vulnerable are opting out and this also happens within public assistance right I mean this yeah this um the part your book talked about federal and the state level but I think the thing I've been thinking more about is like the city level you get out of the sort of left-right thing quickly like if you know naclana jones's writes about schools irrigation a lot and one thing she says is if I get people in urban areas who all voted for hillary essentially to actually believe in school integration that'd be the biggest star forget about you know forget about all you know Nebraska let's what about why is why is new york city the most serrated schools that's what I was thinking is your book really made me think about the way in a lot of urban cities there's a way in which we communicate where it's clear these are the bad schools these are the good schools and we do that over and over again even people who I think are like I'm constantly conversation about people telling me I'm moving to Maryland for this reason in the subtext I'm listening to his oh your school has more than 30 percent but you know like it's coded usually but I know what the words are for that and so I'm getting there at some point that's what I was thinking is how do we so those things can be changed through through interaction like there's a way to communicate in the city level to where this is not bad and this is not black does not mean bad needs to be addressed you know I'm using a racial context here specifically but I think in general even the city level we also do these things and we discriminate based on race in place absolutely so there's one chapter in the book where I focus on cities and how this plays out in cities and I look at Chicago and variation across neighborhoods in Chicago and how that maps on to these kind of dynamics in terms of the linkage between policy and politics and the kind of the takeaway from that is that where urban inequalities are most sharp that's where we really see this policy politics next this being the strongest right but when people are living in places that are flourishing that aren't disorderly that are doing well their interactions with policy even if those interactions are negative don't affect them as much they're not as vulnerable to being alienated by the government when they're living in broader conditions that are actually sending them signals about their value but when you're living in a in in like local conditions that are sending you signals that you're not very valuable and then you have these disempowering interactions with government it's just those things further reinforce each other so I mean thinking about the local aspect of this to me is a little bit more hopeful in the sense that you know it's it's like you said Reggie like our mayor is on board I mean there are spaces there where we can find actors that are willing to operate and there are perhaps there's a base of voters that are right now maybe doing things that don't really align with their values and maybe we can work to raise awareness and change right so there I think that if there's a place where I feel like there there's more room for some of these changes and bringing people in to the electorate and into the political community more broadly it's probably in localities even though there are all sorts of challenges but it's just not as hard and as daunting and maybe we should we can hold some things constant like okay partisan context mostly everybody's democrats we got that constant now let's work on the other stuff and it just kind of makes it a little bit more palatable I think you know I had a thought about cities one of the challenges that faces cities is that in most of the cities in the United States the electorate is a lot more white than the people who live there and so there's an issue where the voting that you just mentioned came in and there's actually a very specific and pretty easy thing that you can do which is change the date of the election so the election for mayor in Chicago I think it happens in mayor april right the election for mayor in New York happens in the odd year right and so those elections when their high turnout might crest 40 percent if you're super lucky but often they're at 30 or low and therefore skewing far away from the kinds of folks who are often recipients of Medicaid right and skewing far away from the demographics of those cities they're pretty exclusive it's a whole different thing on presidential election day in those same exact cities when you have turnout of 60 65 percent double often or triple what a municipal election would be much more representative and the effect by the way of changing that in terms of turnout makes the effect of something like election day registration which is the best single reform we've seen in the literature it it can be a an effect size that's five six seven times higher and we don't have to wonder about whether or not something like that could work because as usual california has already done it so california recognized that this was a problem in la and they're in the process of shifting mayor elections in la la to the on-year they'll be shifted into a couple years they and they gave all the politicians a free extra year to to go and then they passed a law that said in localities across california if they have turnout that is too low and i would read too disproportional but the law just is too low for two cycles in a row then they're just forced to move to the on-year and i think that's the kind of thing which would allow urban policies to be even more at the front lines which ideally is where they where they should be the front lines of you know promoting really good uh egalitarian policy it's a basic acknowledgement i mean that government bears some responsibility at maintaining the infrastructure of democracy making sure that there are points of access for its citizens to influence it right which is supposed to be allegedly its function um that doesn't like shift the onus onto the individuals trying to get out votes trying to get people to show up educating about issues just make it the default right that this is a system that works for them you maximize participation so question mark i'll be quick i'm interested there's a kind of a viewpoint that hasn't really been reflected on the panel although i think you kind of alluded to it at the beginning jimela which is and i don't i don't actually endorse this but it's it's the idea that you know you're just gonna make programs like totally universal everybody gets the same stuff the way social security is that's the only way you get away from this nasty racial politics and of course the problem with that is you you have a you know some there are needs in some places that are not needs in other places but i just wonder i just want to kind of like nudge that viewpoint onto the table and see how you how what responses you have about that right so so yeah i mean i maybe this is just a consequence of sort of being an academic or just my personality which is that i overthink and i'm sort of naturally cynical towards anything that's proposed as a panacea right so it's very often the case that when i talk to people about the book they're like well you did all this research just to basically have us conclude that we need to make this thing universal like da and i'm like okay again i'm not opposed to when it comes to healthcare i actually think i would say this is the case for for more than health care but i think we can make a strong case for health care given the cost of health care the complexity of health care the tremendous burden that health care can put on state and local budgets there are all sorts of reasons why we should make we can make a strong case that if anything should be centralized and universal that it should be health care right and so that's like the low bar we can't even agree on that than the other stuff we can't even start thinking about and so i'm happy to make that that's that's where i i stand but i also don't think that that is ultimately gonna completely get us around some of the different inequalities that emerge in part because the place-based inequalities will still be there and another facet of the argument that i make in the book is that like even when you're getting a policy that looks like it's this it should be the same thing across place you know if we think about within-state variation why is there within-state variation in terms of how people are experiencing and benefiting from and responding to medicate state what the states are offering are generally the same but the places are different and so you don't get around that by like making the program universal which means even beyond saying let's have one universal program we have to keep thinking about how to deal with the kind of place-based heterogeneity of a of a country like the u.s and a universal kind of centralized program gets us somewhere right it gets us a lot of far i think but it doesn't get us around some of the deeper dilemmas i don't know if that was responsive and i i would agree with you and sort of just this is just lina saying like in an ideal world yeah universal health care would be yeah would be great right but you know you're right i mean there's so many other factors and in our real world and our current world where politics play a role and you know not to get too technical but when you think about different types of health systems who have a say in the market that that's that's going to be a that's a big elephant to fight against i think so you know there's so many different stakeholders who you have to think about when we think about you know a broader universal health care system and who has a say and who has financial incentives to to say you know to be in the conversation in one way or another so that's sort of adding an added layer to like you won't take away some of those racial inequalities um class gender inequalities that come into play but then you also have to think you know those stakeholders that that uh that are going to want you know want some financial say in in it as well so another layer of complexity Elizabeth just jumping back slightly to the previous conversation about what can be done look so first of course the election thing is like the health care is deliberate the the reason states have oddier elections is to suppress turnout but specifically thinking about richmond and of course virginia has not yet expanded manacade maybe this week we'll say um so i just wondering if you can talk a little about you know what you can and can't do given that policy context and sort of you know i think we all struggle with what you can move locally and then what you know you really just mean them to take the expansion yeah you know i and this sort of ties into the previous question we have struggled uh as a system of not only government but local government nonprofits about changing our approach from a programmatic to person centric and so yes we have thousands of people in our community who are in need from health care perspective income perspective mobility transportation and i think where we have tripped up in our mega system which is we calculated like a 350 million dollar system for economic mobility with around 191 organizations we're trying to get more granular on exactly who is in this space of moving people out of poverty i just use poverty but i usually don't so this is going to be harder but everyone's story is so different yes there are some people who are trapped because of a medical issue or um in fact here's a story that we heard recently someone walked in to apply for a work program that we had and she put on the application that her last job she used to poll and so when my workforce team uh interviewed her that said what do you mean man she's like 35 years old what do you mean poll she went i'm a stripper and uh she said and my mother has cancer and my children have some disabilities and they're in school and i'm caught because i can't keep doing this much longer but you know but the the health care issue was was was she she realized that she her life had to shift because her body would not be able to maintain the livelihood that you know the way she's been making money so we said well ma'am will we will help you and of course the question was are there about drug use and she said yeah i smoke weed every day in order to self medicate to do this work that i do and so we said well we'll take you in the program but once we found our job for you you probably will have to be drug screen and you can't continue to to smoke weed she did not show up the next day so i know that there are thousands of people this is those are medical issues you know she was being doing being a really responsible daughter and mother because of the weight and burden of the health care system so those are the kinds of stories we hope to relay through local government even to state to to personalize what has sort of turned into like health care medicaid expansion here's this is these are the people and i think that's going to be our role when we talk to the community and gather those kinds of stories period looks like you want to jump in i guess i'm left being the person saying there was an intentional effort to make sure there were no hearings about the bill because the stories would change the policy so we won't have hearings so i mean so it's um because i was thinking about you know more political participation like you'd imagine someone someone started some kind of like organized all the medicaid recipients and state x medicaid state or non medicaid state i can imagine the medicaid program itself would be more responsive to consumers if there was some medicaid recipients group that the providers talked to the state i think that'd be true i don't think those people would have very much political power because despite your students apparently are better or better than i am because i think when four black people walk in the room in real life everyone assumes they're democrats and start to stop listening anyway so i mean in terms you know in the sort of obama care way i'm not sure that your the idea your students are like not listening to d at r until you spring introduce it i don't see so i'm not sure that the in other words i'm not sure that political organizing in terms of like low income groups is going to make much difference in terms of political outcomes i think i'm wrong about that i don't i don't know that you're low power groups i think i think it's complicated right so first of all the thing to realize is that it there are plenty of places where the lion's share of medicaid beneficiaries would be like poor white people right yes and so who identify as republicans and who if they started to push their legislators in more right might actually send a signal to them like now you have to do something so that's an that's that's a possibility that's worth acknowledging even even within the sort of constraints of partisan structures as they are now there's ways that medicaid beneficiaries could exert power right but the other thing to say is like absolutely organizing mobilizing in and of itself right just like okay in the vacuum we get all the medicaid beneficiaries to do something that's going to be effective no because we're not in a vacuum we're in a political context right this is the case for any group right that just getting them out there just mobilizing isn't enough that that needs to be done in ways that are strategic in ways that are that acknowledge sort of political constraints and limitations absolutely right um that being said i think that even in and this is just based on research i did with grassroots organizations during the course of writing the book all over the country even in the states that are most hostile even among the people who uh medicaid beneficiaries i'm shutting down because i know i know what i'm talking about and this isn't it right even those legislators um when you put in a in a context and maybe not so for the big ticket things like medicaid expansion where like there's a lot of party discipline being exerted you're going to vote on we are all going to vote the same way on this you know maybe that's where the ability of beneficiaries or constituents is going to be limited and there's work to be do to be done as far as the organization of the party system to change that but there are plenty of really vital mundane issues that you know you actually can be swayed one way or the other on depending on who's in your office who's in your face who's holding you accountable who so i think there are spaces where these voices can matter and those spaces might not seem like a big deal to us because it's not the big like we're going to expand our universal health care but it's absolutely a big deal for ordinary people who rely on like wait what's going to happen with home health care if home health care goes away i have to be institutionalized or my parent have to those are decisions pennsylvania wanted to mess around with home health care and a lot of the organizations that were that were mobilizing medicaid beneficiaries and other low income people got them to push to exert pressure and they walked it back and things like that happen all the time even in red or relatively hostile places and more of it could happen if more medicaid beneficiaries were were involved and it could matter that doesn't get us out of everything the part that's what i wanted to say was when i was people who are trying to enroll in obama care it was clear that the people who wrote obama care some of whom work you know who i know quite well had not spent a lot of time talking to beneficiaries about here's this computer program which you will sign up for health insurance we would we said something 50 minutes in required in reality you have to all these forms and so on that's what i was getting it was like your book really helped me remember why to everybody i met the people had a really hard time enrolling in health care despite you know brockham saying how easy it was all the time it was not like buying an airline ticket and also everyone actually doesn't have a computer in the first place there's a really bad you know it was a really bad image even but yeah so i agree with you but yeah but this is so important because it just shows that there are some real complexities here there are no sort of easy if we just get more people involved there's a bunch of conditional on other things that need to happen as well i mean it's not it's not easy organizing people on the ground it's it's really challenging and it takes you know years of work to build a base and you're right it's not the only thing that sort of gets you to that policy change you know you have to bring other stakeholders to the table so when we have our advocates on the ground even in you know in virginia talking about medicaid expansion you know you have advocates consumers at the table but who are your other allies who are those provider allies who are the hospitals who are going to benefit from medicaid expansion and sort of thinking about that so when you go to a room full of legislators and they they're going to see each stakeholder that has a say in this that sort of changes the tone of the conversation and speaking of pennsylvania recently you know our advocates connected with a different sector so it was a health sector and the housing sector connected because those are so interconnected in how our health outcomes are impacted and they had a coalition of people went into a legislator's office the legislator said uh-oh you found each other right so it's just sort of you know bringing those right people to the table in addition to organizing and getting those voices out there people who are going to be ultimately impacted by expansion or any other change so let me connect what you were just saying about getting the right people to the table to jamila what you were saying about how there are large swaths of white medicaid beneficiaries who are disadvantaged by what's happening now let me be a little bit provocative you know in the history of social policy especially within the anti-poverty space i mean you see white faces when the political powers that be are looking at program expansion and they become black when it becomes politically expedient for retrenchment right rather than looking at kind of a cross cross racial constituency of organizing advocacy would it just be more effective to make clear how people within the in-group right i mean we didn't design these systems to exclude you guys we did it for everyone else so kind of centering the people who are most like the identity of the people in power this is so good so one of the things that i um i mean of course i'm not going to subscribe to that but but it's it's an important because i think i think we'll do oh yeah i was gonna say it's an important practical question because when i was organizing or interviewing some of these organizations the and i would say well what role do actual medicaid beneficiaries play in your process a lot of them would say oh none actually but the ones who said there's a role would say well stories right we use beneficiaries so that we can bring their stories to the legislators and we teach them how to tell their story and we coach them how to do it we train them and then they go and the stories are impactful and one of the things i i i always said was well which beneficiaries do you choose and based on what criteria because ostensibly some stories are more sympathetic some or more compelling some people are more sympathetic more compelling and they said yeah of course we try we very carefully pick the and then i said oh okay you know you gotta leave them leave the horse to the water um what does race matter like if you have two equally sympathetic women who are medicaid beneficiaries women are more sympathetic and one is a black woman and one is a white woman and here we are in whatever film the blank Missouri like who you're gonna bring to the capital with you and you know i was impressed by their frankness people just said absolutely i mean it's terrible but you bring the white woman right and so the question right which is uh do we censor the in-group is that a strategic way to at that like just repulses me but it's absolutely what's happening and what people who are there's a reason i'm not a politician and and you know the people who are more politically savvy are doing this my the reason it repulses me is not just because you know for the obvious reasons um but the reason it repulses me is because like that's not a long term term sustainable strategy that deepens the divisions builds further upon them and then the decision the divisions become contingent so somehow we're trying to get to equity by capitalizing on inequity right and i just don't think that holds water in the end but again i'm you know i'm not a pragmatist so what do i know i'm sure there's somebody out there well that's why you're not gonna work on my campaign and that's fine i want no part of it so i think we have time for one more question hi thank you so much this has been a great conversation i just had a question around sort of this idea of community engagement we've been talking about and how do we you know when we're trying to bring folks to the table be very intentional to where beyond tokenism we're also placing value in their expertise and avoiding essentially extraction from these communities this is a hard one tokenism is a phenomenon i'm very familiar with and i mean and i say that jokingly but i also say it in a way that's true right where there are plenty of spaces where it's like you're invited into the space because it becomes clear like oh my gosh we did this whole thing and we don't have any you know fill in the blank we don't have any women we don't have any people of color oh you check both boxes come on in and then you get the distinct feeling that you're not really a voice at the table right you're sitting there you're a box check but you're not a voice the question is how do we have engagement that's substantive that's not like we really need to have some Medicaid beneficiaries in the room or else we all feel really guilty and we're not being good liberals and so bring them in the room but then they say something you're like i don't know you don't you don't necessarily really know what you're saying you don't understand the nuances of policy you're not using the right language the right terms you're not articulating it in just the way that all the people in in my circle know how to articulate it and that's a challenge anytime i mean you know even if you think about community health sensors and the boards of community health centers having to have this representation from actual people in the community and there's real variation across centers whether those people have a voices and they're influencing what happens with the centers or whether they're just there because they have to be there by virtue of these criteria that were set up and so you know i think part of i don't know how to you know a lot of this depends on how people are implementing engagement initiatives in real life on why they're doing it and on what sort of what sorts of institutional structures they form to ensure that the that the the people that you bring into the table actually are there in a meaningful way and so i don't know if that's exactly right you know it's the playing field even for everybody so i mean i'll give a really good example of how this played out in Rhode Island where we work with advocates and they're sort of working on a policy issue to influence that impacts both people who are on medicare and medicaid and there is this implementation council that has been set up and you know the goal was to make sure that the implementation council was run co-chaired by consumers who are going to be in this new program and so we said well they need to be trained they need to know that they're going into the meeting so they could be confident so that when they're around the table with providers and state officials or other other you know paid advocates who are doing this for a living that they're also on the same ground and so that's what we did we provided training to our advocates so that they can go out and then train these consumers so that they can sit on the table and what they do now is you provide ongoing training so before every implementation council meeting they will meet separately with the co-chairs and talk about agenda talk about you know how to be engaged in this conversation and build their policy capacity to understand the different terminology and the jargon that goes into health policy so I think it's really important to make sure that like you said the structures are set up in a way so that the playing field is even and that you know there's ongoing training for advocates and consumers who may not be playing this every day you know living in this every day and I might even want training for the other folks in the room who may or may not know how to interact with people who are not in their narrow little circle so the burden of having to learn how to navigate new spaces doesn't overwhelmingly fall on the people who already probably have more hurting so exactly one thing that we have learned in Richmond is there were uh there's a group of people that were always present in front of city council who purported to represent the community and over time they just were really good on their feet and like to express themselves and we created this ambassador program in a way to expand the community voice and and ask people to move out of their comfort zone give them some training but but also say we need you to tell us what your experience is because we know that Miss Jones or Mr. Jones who usually stands up in every council meeting may or may not know you and so here's how we would like you to feel that you have access to government as well and so we train 16 people who want to train at least 20 every year so that we in essence they become the face the ears the the the messengers and also those to relay it back to us in case they don't feel comfortable sitting at one of our tables and this is work on all of our and both sides yeah i find myself thinking about how difficult it is to do this kind of work in a society which is trying oftentimes to be race blind and even more frequently to be class blind and and to present that those things don't exist and so then you have you know frequently community groups where the leaders of the group or the highest income people in the community state or citywide groups where the leaders of that group or the highest income people in the city or state and kind of on and on it goes and i find myself particularly thinking of you know in philadelphia there's the kensington workers or the kensington welfare rights union which is a group of really poor people who work together to try to make their lives better in all sorts of interesting ways one thing they don't really do is give each other money because they don't have it to give but they give each other respect and mutual assistance in ways that are really impressive and they've had to think very carefully about what types of charity and assistance to take and from whom because when will they be surrendering um aspects of control right and when we particularly think about greater and greater levels of economic inequality that are facing us it's really going to be difficult to preserve democracy if we don't confront the challenge of giving people who are at lower levels of socioeconomic class a voice the the roman republic managed to do it for a couple hundred years by having specific government offices which were available only to people from the middle classes obviously they ignored the two thirds who were slaves but they had certain offices that were that they thought we we know that the upper class will dominate the senate etc so they had tribunes we have nothing like that and have never even remotely considered it i don't know that we could but we have to figure out some way to institutionalize across many cities the kind of work that's happening in richmond all right and that's the difference between voice and power right yes i guess your question maybe think of that uh the parkland um the students the movement they had the event they had were i think the students knew who the most palatable powerful influential voice potentially were the white men but they seemed intentionally make sure to include other people i think ultimately you know we know who has the power in our society whites and men usually and ultimately we're gonna need some benevolent members of those people to sort of give some power up and share some power and create solutions to you know share power and make them more inclusive i think it's what we're really talking about here is like all these programs are going to change by people who having power making them change or by us resting by somebody resting power from those people whether or not they benevolently give it up but that's less i get it yeah that's yeah that's it and i think i think that also points to i mean looking at um maybe we would all aspire to live in a place where our government the our society affirms like the shared and equal dignity and humanity of everybody else around us but understanding that's not how we work um realizing that there is a selfish selfish self-interest right and recognizing that racialized systems um uh impact and disadvantage people of all races i mean this is michelle alexander's critique from you know uh the new gem crow right i mean to maintain a veneer of race neutrality there's going to be collateral damage you know with people of different races so i think people who potentially medicate vanish bicheries who are white rather than kind of being centered in the conversation use that platform right to bring attention and visibility to the ways that creating a system to marginalize people of color and particularly black americans works against the interest of of all of us i'd really like to give you the last word in this conversation about your book way too many words already but uh well i'm i'm extremely grateful to all of you for my gosh you have stuck it out over the long haul there's a part of me that wonders like who just comes to something for like two hours to listen to other people see i do these things because i'm the one talking so no thank you all you know what i'm thinking about as we end here is actually so i had a speaker in my public policy class we were doing public policy and local governance and i invited a speaker who's a local county legislator um her name is leslie mithneen claire born first african-american and she's an african-american woman but first african-american person of color at all to ever be a member of the tomkins county legislator i don't know if you guys know much about upstate new york but it's quite white um and she told my student a lot of the students wanted to know like well tell us your story you know and she told them about how she was low income she was a medicaid beneficiary she she was a you know section eight on section eight vouchers she was working low wage jobs uh trying to take care of her family just having a really hard time but always wanted to be involved in our community engaged in the community going to community events and something happened with one of the sitting um county legislators and they had to oh they moved to a different county which surprise if you if you don't live in the county you can't be on the legislature so they really needed somebody quick who who could fill in and she and they were like you're always at the meetings you know about the community care about the community why not you and she said she walked into a room one day and they said we're gonna start a a political group for you we're gonna try to get you in this spot and it worked out she's a county legislator but she's still low income county legislators at this time in top against county get like i don't know a couple thousand dollars a year not enough to live on because everyone else on the legislature is essentially an old white man or woman who's independently wealthy retired not doing this for the money and she's still raising small children still working full time and the rest of them aren't and she proceeded to take my students through the story of saying like i you know i was engaged i i was in a i got a position where i had a voice where i had voice right i was at the meetings right but i didn't have power because i was very differentially positioned relative to everyone else so i was at the meetings and i spoke my piece it didn't matter i couldn't spend as much time on it i couldn't engage with my constituents as much and it was just the students were really struck by the challenges of securing real power from the margins and even someone who was standing in front of them who seemed compelling who seemed admirable and who was literally in a position where she had a voice still had a tremendously difficult time being heard and making a difference and that kind of i think taps into a lot of the underlying currents of this conversation with how do what does it mean for us to to think about people having power being empowered who are not already in that position right and who don't look like and have the advantages of the people who are generally in those positions and how does public policy affect the likelihood of that kind of power being enacted and how do political institutions how do parties all of these different challenges are about thinking about how to empower people who otherwise do not have power and who are otherwise relegated to the sort of political margins and we obviously did not encounter any answers but i think that we had a lot of ideas that matter and that a stench it's the development the continued generation development of these ideas and and hopefully the kind of enactment of some of these ideas that gets us closer to a place where i don't feel like it's all pie in the sky which i often do but that it's it's a real possibility for us to live in a country that is an actual equal democracy that's a great place to end things and the good news is you'll have a chance to find out who comes to these things and stays for two hours at our reception please join me in thanking our panel and jamila