How Health Policies Affect Health Equity People, Places, Power: Medicaid Concentration and Local Political Participation Jamila D. Michener Cornell University Abstract The geographic concentration of disadvantage is a key mechanism of inequity. In the United States, the spatial patterning of disadvantage renders it more than the sum of its individual parts and disproportionately harms economically and racially marginalized Americans. This article focuses specifically on the political effects of Medicaid beneficiaries being concentrated in particular locales. After offer- ing a framework for conceptualizing the community-wide consequences of such policy concentration, I analyze aggregate multiyear data to examine the effect of Medicaid density on county-level voter turnout and local organizational strength. I find that, as the proportion of county residents enrolled in Medicaid increases, the prevalence of civic and political membership associations declines and aggregate rates of voting decrease. These results suggest that, if grassroots political action is to be part of a strategy to achieve health equity, policy makers and local organizations must make efforts to counteract the sometimes demobilizing “place-based” political effects of “people- based” policies such as Medicaid. Keywords Medicaid, concentrated disadvantage, political participation “Place matters” in profound, multitudinous ways and it is acutely conse- quential for those who inhabit the economic and racial margins of Amer- ican society (Dreier, Mollenkopf, and Swanstrom 2004). The power of place is neither incidental nor innocuous. Instead, the social, economic, and political significance of where a person lives stems from public policies that create, contour, and reinforce systemic inequity. One way that policy does this is by facilitating the geographic concentration of people who are structurally vulnerable. Concentration is a mechanism through which Journal of Health Politics, Policy and Law, Vol. 42, No. 5, October 2017 DOI 10.1215/03616878-3940468 Ó 2017 by Duke University Press Downloaded from https://read.dukeupress.edu/jhppl/article-pdf/508755/865michener.pdf by guest on 26 November 2017