Making The Political Personal: Health Insurance, State Visibility, And Civic Perceptions

Over the past half-century, much of the growth in US government programs has been carried out by non-state actors, creating the so-called hidden or submerged state.� For instance, although Medicaid is a government-funded health insurance program, private entities administer most Medicaid insurance plans.� In this dissertation, I identify how shifting administrative authority away from the state generates attitudinal distortions that ultimately serve to reinforce public support for the submerged state.� This process functions in multiple steps, which I refer to as the Privatize-Attenuate-Distrust-Divest (PADD) cycle.� First, I show that privatizing social programs introduces hurdles that attenuate the role of government, causing the policy’s target populations to underestimate when they are directly affected by this government initiative.� Next, I connect these distorted perceptions of government’s relevance to decreased trust in government.� I conclude by showing that diminished trust in government enhances support for submerged policy mechanisms and the rhetorical strategies that undergird them, creating a political environment that is ultimately more favorable to the continued enactment of policies that divest government of administrative authority. I study this process in the context of Medicaid managed care and federal contraceptive policies using a series of observational surveys and original survey experiments. Overall, this research underscores the relationship between policy submersion and democratic accountability.� It shows that the proxy administration of public policies can fracture the basic premise of democratic accountability by distorting perceptions of whether government affects you personally, and it demonstrates that these distortions have tangible consequences for how people evaluate government.