Jamala Michener knows how the government works for people—and how it doesn't. A professor at Cornell and co-director of the Cornell Center for Health Equity, Michener has spent her career researching the intersection of power, poverty, racial inequality, and public policy in America. Her recent book, Fragmented Democracy: Medicaid, Federalism, and Unequal Politics is a searing report on how and why Medicaid—and America's healthcare system—doesn't help those who need it the most.
We called up Michener to talk about what she hears from government staffers, democratizing policymaking, and how we can make public policy and public benefits work better for everyone.
Where to Next: How do we make more human-centered policies?
Jamala Michener: That's a hard question. It starts with: Where are people? It's a question about how you democratize policy processes, to make them more accessible to more people. Because human-centered policy can only come from maximally democratic policy processes.
Currently, the role that people play in the policy process is they vote for their elected officials and those elected officials make policy. They're the ones who engage with the lobbyist and other interest groups who try to influence the policy process. But you get this one input from people at the beginning, which is to vote for their elected officials. And then often that's the only input!
Now, sometimes there are other kinds of signals along the way: people write letters to their political representatives or they reach out to them in various ways. Grassroots organizations and advocacy organizations that represent particular people or communities sometimes try to influence those elected officials—and those are some additional pathways for connecting people to the policy process in a way that's more robust than just the blunt instrument of a vote.
Human-centered policy necessitates a much more robust vision of what it means to have people involved in and embedded in policy processes. Human-centered policy design means finding, creating, and building additional channels for a wider swath of people to have a deeper say over what happens with policies, especially the policies that are most important in their own lives.
I'll give you an example. Yesterday, I was having such a conversation with some Senate staffers about policy. They wanted to think about how to integrate equity principles into policymaking. And they asked me to think through some policies with them that they were working on; and to try to help them kind of grapple with how to approach those policies from an equity perspective.
The main thing they said to me is: we're not sure that we're including people's voices and perspectives. We think this is a good policy and we think it's going to help people, but what if there's some kind of blind spot, because we're not sufficiently including people's voices and perspectives? And I started trying to brainstorm with them about pathways for doing that. But those aren't already there for them. They have to say, well, this is our normal process, and it produced this policy; if we want to make sure people's voices are included, how would we do that?
The government staffers who work on policy are asking you how to make more human-centered policies because they don't know where to start?
It's not part of the process for them. The people who are most affected by any given policy are not in any natural institutionalized way a part of the process. They have to go out of their way to try to make that happen. So for me, a big question is how can we start to institutionalize a more robust democracy—not minimal democracy where people vote and then everything else is up to policymakers. But deep democracy, that means people vote and then at every point possible in the process thereafter we're integrating the people with the most at stake who are most vulnerable and who are most marginal, to make sure that their perspectives and needs and voices are incorporated.
If we're trying to build better policies focused on our citizens, where does that start? At the grassroots level? Does it start with community-based organizations (CBOs) doing on-the-ground work? What does it look like if we're trying to better engage our citizens and create a better experience of government for them?
There are a few different places that it could start. CBOs can absolutely be important as a starting point—for a variety of reasons. One is that often, they're already involved in people's lives in ways that are helping to address needs they have. They've built community trust and there's a connection there that can be leveraged to draw people in. That can be valuable and a good place to start.
Government agencies are also a good place to start. Government has a wider reach. Especially when we think about people who are economically or racially marginalized; government plays an outsized role in those people's lives. So I wouldn't exclude government as a potential source for connecting with and reaching communities.
Pain points, I like that framing. Because it really is painful for people.
So, for example, I've been working with some folks in the state of Kentucky who are in charge of public benefits agencies and really trying to understand how to make the experiences that people have when they come to these agencies more humane.
It's really interesting working with people within state government, who have that explicit focus and who are looking to learn—and who, instead of just coming up with the answers off the top of their head, are asking “how can we work together to really systematically learn about people's experiences?” And so I'm working with them to do in-depth interviews and really talk to people and understand a wide range of people: hundreds of people across different public benefits programs, who live in different parts of the state, people in urban areas, people in rural areas, to really get a range of experiences.
So we're really trying to bring in user voice to the public policy and public benefits process.
The problems with delivering benefits in America in a dignified way is a failure of policy and imagination—at the federal, state, and local level. There's a real lack of imagination. And it's a tangled web, because the delivery of benefits is so regional, even though many of the programs, like SNAP, are federal they are run state-by-state and county-by-county. I'm wondering, what are some of the pain points in delivering benefits right now? And how could we make that more dignified for people receiving them?
Pain points, I like that framing. Because it really is painful for people.
And it's humiliating, when it doesn't need to be.
Exactly, it really is. This is particularly top of my mind, because of this study I've been doing. We're literally talking to people about their experiences with Medicaid, SNAP, and WIC; and asking them essentially, this question, which is, how's it going? What is the experience and the process of getting these benefits like?
One thing that stood out is the extent of administrative burdens that people are faced with. Just the amount of paperwork you have to fill out and how often you have to fill out that paperwork. And often, if you're interacting with more than one government agency or program, you're having to replicate that across the agencies. But there are small enough differences that you did this with SNAP and so you think you know all the paperwork that Medicaid needs to give them all the paperwork they need, because you just gave it to SNAP, but then it turns out, they need one other thing, or you didn't quite fill it out right from that. And then there's this cascade where you lose your benefits. Some states have lockup periods, which once you've lost your benefits, you can't get back on for a certain amount of months.
So it's a paperwork problem. Can it be centralized?
I think some level of centralization would be great. But I think it's really hard. In a state like Pennsylvania, the WIC is in the Department of Health and Medicaid in the Department of Human Services. Departments have different budgets, even as they report up on a state level and a federal level—they're reporting to different people in different agencies. And those agencies have different regulations about how quickly you have to respond to the applications and how quickly you have to get people enrolled.
It sounds easy to just centralize everything. But, from the federal level on down there are these silos: these are literally different forms that are located differently, have different incentives, and structures. So aligning all that and centralizing it would be extraordinarily hard. It doesn't mean it's not possible. But I see that as more of a long-term goal. And it's a heavy political lift.
Is there a way to make it more dignified in the meantime?
Yes, and it starts with the people who work at the agencies and interface with the beneficiaries. Because they actually have a ton to do with how beneficiaries feel in terms of them being treated with dignity.
You can have a lot of paperwork to fill out. But if you have someone there patiently explaining to you what you have to fill out, guiding you and helping you through in a way that's kind and courteous? That changes a lot for people. We often hear people say “yeah, the paperwork is really burdensome. But if the people weren't so mean, it wouldn't be nearly as bad.”
So there's a role for both figuring out how to minimize the burden and structure the systems in a more streamlined way so that it's easier for people to access. But even streamlined and easy-to-access systems that are implemented on the ground by people who are rude or mean to beneficiaries are still not going to be dignity enhancing. There has to be some balance between the systems approach on a kind of technological or infrastructural level, and the systems approach on a human level—the people who are actually implementing those systems.
That means designing incentives for the people implementing those systems to treat people like people. If you interview the bureaucrats, most of them are saying, “I'm trying as hard as I can. I took this job because I want to help people. But we have to fill out so much paperwork. We have to meet so many regulations. We have to interface with so many systems, and we have so many deadlines and get paid very little for doing it all.”
The one thing I tell people is when we think about administrative burden, not just thinking about it in relation to the beneficiaries, but also in relation to the workers who have to process the paperwork—because they deal with the beneficiaries. And they're a huge part of the human component that makes the beneficiaries feel like they're not being respected and treated with dignity.
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