Healthy Voices, Unhealthy Silence: Advocacy and Health Policy for the Poor (American Governance and Public Policy)

171 Pages·2007·0.43 MB·English

by  Colleen M. Grogan

Healthy Voices, Unhealthy Silence
SELECTED TITLES from the American Governance
and Public Policy Series
Series Editors: Gerard W. Boychuk, Karen Mossberger, and Mark C. Rom
After Disaster: Agenda Setting, Public Policy, and Focusing Events
Thomas Birkland
Ambiguity and Choice in Public Policy: Political Decision Making in Modern
Democracies
Nikolaos Zahariadis
Branching Out, Digging In: Environmental Advocacy and Agenda Setting
Sarah Pralle
Budgeting Entitlements: The Politics of Food Stamps
Ronald F. King
Collaborative Public Management: New Strategies for Local Governments
Robert Agranoff and Michael McGuire
Controlling Technocracy: Citizen Rationality and the NIMBY Syndrome
Gregory E. McAvoy
Dam Politics: Restoring America’s Rivers
William R. Lowry
The Education Mayor: Improving America’s Schools
Kenneth K. Wong, Francis X. Shen, Dorothea Anagnostopoulos, and
Stacey Rutledge
Expert Advice for Policy Choice: Analysis and Discourse
Duncan MacRae Jr. and Dale Whittington
Federalism and Environmental Policy: Trust and the Politics of Implementation,
Second Edition, Revised and Updated
Denise Scheberle
Federalism in the Forest: National versus State Natural Resource Policy
Tomas M. Koontz
Fenced Off: The Suburbanization of American Politics
Juliet F. Gainsborough
From Revenue Sharing to Defi cit Sharing: General Revenue Sharing and the Cities
Bruce A. Wallin
Globalization and the Politics of Pay: Policy Choices in the American States
Susan B. Hansen
The Government Taketh Away: The Politics of Pain in the United States and
Canada
Leslie A. Pal and R. Kent Weaver, Editors
Healthy Voices, Unhealthy Silence: Advocacy and Health Policy for the Poor
Colleen M. Grogan and Michael K. Gusmano
How Governments Privatize the Politics of Divestment in the United States and
Germany
Mark Cassell
Improving Governance: A New Logic for Empirical Research
Laurence E. Lynn Jr., Carolyn J. Heinrich, and Carolyn J. Hill
Lessons of Disaster: Policy Change after Catastrophic Events
Thomas Birkland
Lobbying Together: Interest Group Coalitions in Legislative Politics
Kevin W. Hula
Making Policy, Making Law: An Interbranch Perspective
Mark C. Miller and Jeb Barnes, Editors
Metropolitan Governance: Confl ict, Competition, and Cooperation
Richard C. Feiock, Editor
Pluralism by the Rules: Confl ict and Cooperation in Environmental Regulation
Edward P. Weber
Policy Entrepreneurs and School Choice
Michael Mintrom
The Politics of Automobile Insurance Reform: Ideas, Institutions, and Public
Policy in North America
Edward L. Lascher Jr.
The Politics of Ideas and the Spread of Enterprise Zones
Karen Mossberger
The Politics of Unfunded Mandates: Whither Federalism?
Paul L. Posner
Power, Knowledge, and Politics: Policy Analysis in the States
John A. Hird
Preserving Public Lands for the Future: The Politics of Intergenerational Goods
William R. Lowry
School’s In: Federalism and the National Education Agenda
Paul Manna
The Shadowlands of Conduct: Ethics and State Politics
Beth A. Rosenson
Taking Aim: Target Populations and the Wars on AIDS and Drugs
Mark C. Donovan
Ten Thousand Democracies: Politics and Public Opinion in America’s School
Districts
Michael B. Berkman and Eric Plutzer
Terra Incognita: Vacant Land and Urban Strategies
Ann O’M. Bowman and Michael A. Pagano
Transatlantic Policymaking in an Age of Austerity: Diversity and Drift
Martin A. Levin and Martin Shapiro, Editors
Virtual Inequality: Beyond the Digital Divide
Karen Mossberger, Caroline J. Tolbert, and Mary Stansbury
Welfare Policymaking in the States: The Devil in Devolution
Pamela Winston
Healthy Voices, Unhealthy Silence
Advocacy and Health Policy
for the Poor
C M. G
OLLEEN ROGAN
and
M K. G
ICHAEL USMANO
Georgetown University Press / Washington, D.C.
As of January 1, 2007, 13-digit ISBN numbers have replaced the 10-digit system.
13-digit 10-digit
Paperback: 978-1-58901-182-3 Paperback: 1-58901-182-1
Georgetown University Press, Washington, D.C. www.press.georgetown.edu
© 2007 by Georgetown University Press. All rights reserved. No part of this
book may be reproduced or utilized in any form or by any means, electronic
or mechanical, including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from the publisher.
Library of Congress Cataloging-in-Publication Data
Grogan, Colleen M.
Healthy voices, unhealthy silence: advocacy and health policy for the
poor / Colleen M. Grogan and Michael K. Gusmano.
p. ; cm. (American governance in public policy series)
Includes bibliographical references and index.
ISBN-13: 978-1-58901-182-3 (pbk. : alk. paper)
ISBN-10: 1-58901-182-1 (pbk. : alk. paper)
1. Medicaid—Connecticut. 2. Patient advocacy—Connecticut. 3. Health
care reform—Connecticut. 4. Poor—Medical care—Connecticut. 5. Health
services accessibility—Connecticut. 6. Equality—Heath aspects—Connecticut.
I. Gusmano, Michael K. II. Title.
[DNLM: 1. Medicaid—economics—Connecticut. 2. Advisory
Committees—Connecticut. 3. Health Care Reform—economics—
Connecticut. 4. Health Policy—economics—Connecticut. 5. Health
Services Accessibility—economics—Connecticut. W 250 AC8 G874h 2007]
RA412.3.G76 2007
368.4’2009746—dc22

2007007010
∞ This book is printed on acid-free paper meeting the requirements of the
American National Standard for Permanence in Paper for Printed Library
Materials.
14 13 12 11 10 09 08 07 9 8 7 6 5 4 3 2
First printing
Printed in the United States of America
This page intentionally left blank
Contents
Preface ix
Acknowledgments xi
Introduction 1
1 The Problem and Puzzle of Public Silence 3
Part I Explanations and Background 21
2 E xplanations for Public Silence: Inequality,
Dependence, and Infeasibility 23
3 M edicaid’s Persistent and Confl icting Goals: Equal
Access, Quality Care, and Cost Control 42
Part II Arguments and Findings 67
4 T he Political and Policy Diffi culties of Discussing
Unequal Access 69
5 M edicaid’s Policy Network and the Ties that Bind:
Nonprofi t Advocacy and Social Interactions 91
Conclusion 119
6 M edicaid Reform and Advisory Boards: Who Will
Advocate for Poor People’s Health? 121
Notes 131
References 137
Index 151
This page intentionally left blank
Preface
T
his book deals with two enduring themes in most advanced de-
mocracies: the persistence of political inequality and the desire to
shape “good” social welfare policy. Although these themes are ubiq-
uitous in any public policy problem, we didn’t actually intend to
address them. We started this project in the mid-1990s with an in-
terest in how state governments were attempting to improve health
care for the poor in the United States. When the state of Connecti-
cut, like most states at the time, decided to reform its Medicaid pro-
gram—the nation’s health care program for the poor—we naturally
thought it was a good opportunity, as we were both at Yale Univer-
sity at the time, to study state policy decision making. So we headed
up to the state capital in Hartford to interview state legislators, state
bureaucrats, and advocates—the major stakeholders—with the
thought of conducting a traditional implementation study.
Like most states, Connecticut had established a state advisory
board to discuss major issues of concern and to advise the agency
responsible for administering the reform on important policy de-
sign and implementation issues. Like diligent data-collecting social
scientists, we started attending these meetings not because we had
a high opinion of state advisory boards but because we thought
this was a useful avenue to begin meeting important stakeholders.
Because the literature on state advisory boards and state participa-
tory processes, especially that written about health planning boards
from the 1970s, generally described these processes as token exer-
cises where powerful voices tend to dominant and disenfranchised
groups are not given adequate opportunity to be heard, we didn’t
expect much from the meetings. But after attending sixty-seven
meetings over an eighteen-month period, taking copious notes and
reading over the transcriptions from the public discussions, we had
to take pause.
We paused for several reasons. First, when we looked at who was
included in the participatory process, we noticed that a sizable por-
tion of participants were advocates for the poor or providers who