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policy advocates. As Chapter 7 makes clear, policy advocacy among Medicaid beneficiaries is rare. Nevertheless, her interviews reveal how beneficiaries connect and mobilize through Facebook message boards. In some respects, the evidence here points to a more positive assessment of federalism, illustrating how beneficiaries exploit multiple institutional venues and draw on evidence of effective advocacy in other states to press their claims. Yet the balance sheet has its share of liabilities, too. The federal–state design of Medicaid creates a steep learning curve for advocates, allows political elites to shift blame when under attack, and fragments access to civil legal aid resources that support beneficiaries. It would be tempting to interpret the evidence in Fragmented Democracy as merely suggesting that stingy states, biased bureaucrats, and neglected neighborhoods have weakened American democracy. Michener demonstrates those patterns empirically, with fidelity to the diversity and complexity of intergovernmental relations. But her final analysis cuts deeper, targeting the macroinstitution of federalism as a barrier to political participation. As numerous civil and political rights depend on state and local officials for their enforcement, this argument has implications beyond Medicaid itself. If federalism is indeed a “concept of the mind,” this book should inspire policymakers and scholars to think more carefully and critically about how to mitigate its most deleterious effects on democratic citizenship.