Studies of American federalism face a fundamental analytical challenge. The federal “system” is neither a fixed institutional arrangement nor a physical object. It is instead––to borrow a phrase from the late William Anderson––a “concept of the mind.” To make sense of the diversity and complexity of intergovernmental relations, scholars conceptually and empirically bound their studies in ways that affect our understanding of the system’s virtues and vices. In this groundbreaking book, Jamila Michener draws a new and vital map of American federalism that illustrates how geographical inequalities in social provision lead to a weaker democracy.

The book begins as assuredly no study of American federalism ever has: in a burger joint on the outskirts of Atlanta. There we meet Terrie, a middle-aged black woman who informs Michener of her struggle to gain adequate benefits through Medicaid, the largest source of public health insurance in the United States and the primary means of coverage for low-income Americans. As Terrie informs us, Medicaid benefits vary wildly from state to state. While living in Ohio, California, and Washington, she always had Medicaid, but after moving to Georgia, her benefits were cut off because she had a part-time job, even though she could not afford insurance. Rather than mobilizing her to fight back, Terrie’s experiences with Medicaid are disempowering: “You have no say, no say in the process if you don’t agree with what is going on in Medicaid” (p. 3).

As this opening scene illustrates, Michener trains her focus on how federalism––a system of government that allocates vital resources on the basis of geography rather than rights or needs––affects the political lives of democratic citizens. This sets Fragmented Democracy apart. Numerous studies evaluate how democracy affects federalism––that is, how public officials compete for power in the federal system, and how politics shapes (or distorts) the equilibrium of power between levels of government. Yet as Carol Weissert has noted, U.S. federalism scholarship tends to ignore issues of democratic representation (“What U.S. Federalism Scholars Can Learn from Comparative Work,” Journal of Politics, 73(4), 2011).

Fragmented Democracy helps to address this normatively significant gap in the literature by integrating and expanding on models of participation that emphasize individual characteristics, meso-level institutions, sociopolitical contexts, and policy feedback. In Michener’s “contextualized feedback” model, federalism creates variation in citizens’ access to important resources and in their sociopolitical contexts (pp. 26–30). These varying experiences with public policy offer citizens divergent lessons about the value of participating in politics (e.g., voting, joining a political group, attending a rally) or engaging in “particularistic resistance” (e.g., appealing an unfavorable decision by a bureaucratic agency).

Wisely, Michener uses Medicaid as the empirical setting for evaluating this broader argument. As with other intergovernmental programs, Medicaid benefits and eligibility rules vary considerably from state to state, affording empirical leverage on the link between program design and political participation. Yet Medicaid is not merely one intergovernmental program among others. Its status as the largest-existing federal-state program make it an ideal index of how American federalism shapes contemporary political life.

The book’s empirical backbone is composed of in-person interviews with 45 Medicaid beneficiaries and 16 key stakeholders (e.g., benefits lawyers, nonprofit directors, and front-line workers). By elevating the lived experiences of beneficiaries, Michener provides us vital evidence that is all too often missing from legislative hearings on Medicaid and the technocratic prose of white papers. Interviews confirm the prevalence of stigma, administrative burdens, and capricious behavior in state Medicaid programs. As one beneficiary puts it, it is only by the “grace of God” that her family receives the health care that she needs (p. 68). Perhaps more importantly, beneficiaries experience geographic variation in benefits as barriers to coverage and administrative burdens of their own. Moving to a new state invariably means confusion and worry regarding which services and treatments will be covered.

These interview data motivate several well-designed quantitative analyses investigating the link between Medicaid program design and political participation. Chapter 4 offers the most pivotal test of Michener’s argument. Drawing on a cohort study of the parents of 5,000 children, the author shows that “compared to others in the [sample], respondents who indicated being Medicaid beneficiaries are significantly less likely to vote, register, and participate [in politics] more generally” (p. 77). State policies that narrow the scope of benefits help to account for this effect. Michener finds that state reductions in Medicaid benefits exert a large and statistically significant effect on participatory behavior: “[C]ompared to beneficiaries living in states that did not reduce benefits, beneficiaries living in states that had made the most reductions were between four and nine percentage points less likely to vote, register, or participate” (p. 82).

Fragmented Democracy also answers Ann O’M. Bowman’s call for more careful attention to state–local relations in the federal system (“The State–Local Government(s) Conundrum: Power and Design,” Journal of Politics, 79(4), 2017). Chapter 5 examines the role of county government, an often-ignored but critical component of Medicaid administration in many states. Interactions with county-level officials structure beneficiaries’ views of their socioeconomic status and race, as well as their perceptions of government responsiveness. When beneficiaries have negative interactions, they are less likely to appeal adverse state actions, including denial and termination of benefits. While Michener’s data do not unpack the reasons why county-level patterns vary from state to state, her analysis offers an excellent basis for future scholarship (pp. 110–13). Chapter 6 evaluates how varying neighborhood contexts affect Medicaid beneficiaries’ political participation in the city of Chicago. Whereas Medicaid is a person-based policy, the evidence here shows the collateral effects of neglecting place-based programs. Beneficiaries have a lower probability of participating in politics when they receive Medicaid services in clinics surrounded by higher levels of perceived social disorder and lower levels of social cohesion.

While many studies of policy feedback might stop here, Michener extends the analysis to consider how the fragmented federal system affects the efforts of organized policy advocates. As Chapter 7 makes clear, policy advocacy among Medicaid beneficiaries is rare. Nevertheless, her interviews reveal how beneficiaries connect and mobilize through Facebook message boards. In some respects, the evidence here points to a more positive assessment of federalism, illustrating how beneficiaries exploit multiple institutional venues and draw on evidence of effective advocacy in other states to press their claims. Yet the balance sheet has its share of liabilities, too. The federal–state design of Medicaid creates a steep learning curve for advocates, allows political elites to shift blame when under attack, and fragments access to civil legal aid resources that support beneficiaries.

It would be tempting to interpret the evidence in Fragmented Democracy as merely suggesting that stingy states, biased bureaucrats, and neglected neighborhoods have weakened American democracy. Michener demonstrates those patterns empirically, with fidelity to the diversity and complexity of intergovernmental relations. But her final analysis cuts deeper, targeting the macroinstitution of federalism as a barrier to political participation. As numerous civil and political rights depend on state and local officials for their enforcement, this argument has implications beyond Medicaid itself. If federalism is indeed a “concept of the mind,” this book should inspire policymakers and scholars to think more carefully and critically about how to mitigate its most deleterious effects on democratic citizenship.