Out of Sight, Out of Mind? Measuring the Relationship between Privatization and Medicaid Self-Reporting

Privatization has grown exponentially, both in salience and in form, over the past several decades. This shifting of administrative authority away from the state can make it difficult for program recipients to link their use of a federal program back to government, a disconnect known as “submerging” the state. However, privatization is a process that occurs in degrees, and not all privatization initiatives look alike. This study leverages variation in the implementation of Medicaid managed care, which is the most widespread form of Medicaid privatization, to examine how privatization maps onto state submersion and affects state visibility. This analysis shows that, although Medicaid managed care enrollment, at large, does not relate to recipients' self-reported Medicaid enrollment, when privatized Medicaid plans introduce administrative designs that obscure the role of government, Medicaid self-reporting declines. These findings demonstrate that policy recipients are less able to recognize both the personal relevance of a specific public program and the public nature of this interaction when privatized programs utilize design features that attenuate signals of government involvement. In highlighting this disconnect, this article shows how privatization makes it more difficult for policy recipients to engage in the civic sphere as informed advocates for their self-interest.