Jamila Michener examines how Medicaid, the health insurance program for low-income Americans, shapes its beneficiaries' relationship to government and politics. Because Medicaid is jointly administered by federal and state governments, its benefits and requirements vary dramatically across states, creating very different experiences of government depending on where one lives. Michener draws on surveys, interviews, and fieldwork in New York, Florida, and other states to show how these differences affect political engagement. She finds that Medicaid's fragmented structure teaches beneficiaries different lessons about what to expect from government and whether participation is worthwhile. In states with more generous programs and accessible bureaucracies, beneficiaries develop more positive views of government and participate more actively in politics. In states that make Medicaid difficult to access and humiliating to receive, beneficiaries learn that government is unresponsive to their needs and disengage from political participation. Michener demonstrates that federalism, often celebrated as allowing policy experimentation, produces systematic inequalities in democratic citizenship. She challenges political scientists to take poverty seriously as a lens for understanding American politics, showing how material conditions shape the possibilities for democratic participation. The book reveals how policy design choices that seem technical actually have profound consequences for whether poor Americans experience themselves as citizens with voice or supplicants dependent on bureaucratic grace.