Former CCHEq co-director at forefront of healthcare access discussions

Throughout her academic career, the intersection of poverty, racial inequality and public policy — and its impact on individuals — has moved Jamila Michener, PhD, a former co-director of the Cornell Center for Health Equity and an associate professor of government and public policy.

Her 2018 book “Fragmented Democracy: Medicaid, Federalism and Unequal Politics” explores how the program’s structure reinforces disparities and affects political engagement. It won an award from the American Political Science Association for the best book on state politics and policy. She also writes about health equity in journals and the popular press, speaks at national events and appears on podcasts and news shows. 

That background led to an invitation in the summer of 2022 to testify before the Committee on Oversight and Accountability (formerly the Committee on Oversight and Reform) at the U.S. House of Representatives. The committee, then led by Democrats, sought to examine pathways to universal health insurance coverage, including a proposed Medicare for All Act.

While the uninsured portion of the population had dropped to 8 percent that spring – an historic low – that share still represented more than 26 million people. Millions more were underinsured, with their plans’ high deductibles and out-of-pocket costs essentially leaving healthcare out of reach.

The need remained concentrated in particular communities — often rural or heavily segregated — and in states choosing not to pursue Medicaid expansion. Once again, it fell disproportionately on marginalized populations, including low-income residents and people of color.

Testimony in Congress
In her testimony, Michener laid out the impact, based in part on her research: People without adequate insurance often delay or forgo care, have trouble filling prescriptions, and face obstacles to following medical recommendations. Those challenges intertwine with racial disparities in health outcomes, among a wide range of preventable or treatable conditions.

 “Access to health insurance is a critical determinant of whether health equity could be a reality,” she told the committee. She later added that universal coverage could also help narrow disparities in educational attainment and economic security.

Ultimately, despite securing 122 cosponsors, the Medicare for All bill stalled in various House committees, never coming to a floor vote. That outcome was not a surprise, Michener says, but it was also not the principal motivation.

“We don’t want people to be able to forget that these disparities in accessing healthcare exist,” she says. “We don’t want this to be a conversation that falls off the radar in the context of our political polarization.”

To that end, the hearing did spur further possibilities, with Michener hearing afterward from a range of policymakers seeking advice.

Potential policy changes
One pathway could focus on gaining insurance coverage for discrete populations within the larger group. Potential policy changes could allow states to extend Medicaid to juveniles during incarceration and immediately after, for example. Or governments could offer subsidies to companies or individuals to insure more low-wage workers. Such smaller scales can change the political calculus, the thinking goes, reshaping actors and alignments to gain traction.

“You want the big picture, but each of the little things matter as well,” says Michener. “If we can’t ensure healthcare for everyone, what are the groups we can carve off to help? Let’s see where we can move the needle.”

Another impact came from Michener taking a more expansive approach in her Congressional appearance, going beyond the health and fiscal benefits of insurance. Drawing in part on her research, she told the committee that healthcare access can also strengthen democracy. Voter turnout rises with Medicaid expansions and also falls with loss of eligibility, for example.

From the White House to state government
That testimony gained particular notice, says Michener, and resulted in an invitation the following February to the White House for one of the Biden administration’s Evidence Forums. Created to ensure promising research results benefit the lives of Americans, the meetings touted equity as one keystone.

Speaking to a crowd that included leaders from federal agencies, Michener advocated an inclusive approach to policy-making around health — not only do results matter, but also the methods, she told attendees.

“How are you doing the policy-making?” she says, summarizing her theme. “Are the people for whom the most is at stake incorporated in your processes? What would that look like and what are the consequences if they’re not?”

That talk, too, has led elected officials, staffers in state and federal agencies, and leaders of advocacy organizations to reach out for consultations. Not only can those discussions help inform future policies, Michener says, but they further the center’s goal of partnering with everyone from local community groups to the highest reaches of power.

“It pulls a thread through all of our work,” she says. “We not only want to help people understand specific policy issues but also what it means to pursue health equity — whose voices have to be heard, and what processes have to be catalyzed and followed through on.”