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

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 Deficit 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: Conflict, Competition, and Cooperation Richard C. Feiock, Editor Pluralism by the Rules: Conflict 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

COLLEEN M. GROGAN and

MICHAEL K. GUSMANO

Georgetown University Press / Washington, D.C.

As of January 1, 2007, 13-digit ISBN numbers have replaced the 10-digit system. 13-digit Paperback: 978-1-58901-182-3

10-digit 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

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Contents

Preface

ix

Acknowledgments

xi

Introduction

1

1

The Problem and Puzzle of Public Silence

3

Part I

Explanations and Background

21

2

Explanations for Public Silence: Inequality, Dependence, and Infeasibility

23

Medicaid’s Persistent and Conflicting Goals: Equal Access, Quality Care, and Cost Control

42

Part II

Arguments and Findings

67

4

The Political and Policy Difficulties of Discussing Unequal Access

69

Medicaid’s Policy Network and the Ties that Bind: Nonprofit Advocacy and Social Interactions

91

3

5

6

Conclusion

119

Medicaid Reform and Advisory Boards: Who Will Advocate for Poor People’s Health?

121

Notes

131

References

137

Index

151

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Preface

This book deals with two enduring themes in most advanced democracies: the persistence of political inequality and the desire to shape “good” social welfare policy. Although these themes are ubiquitous in any public policy problem, we didn’t actually intend to address them. We started this project in the mid-1990s with an interest in how state governments were attempting to improve health care for the poor in the United States. When the state of Connecticut, like most states at the time, decided to reform its Medicaid program—the nation’s health care program for the poor—we naturally thought it was a good opportunity, as we were both at Yale University 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 design 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 participatory processes, especially that written about health planning boards from the 1970s, generally described these processes as token exercises 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 portion of participants were advocates for the poor or providers who

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PREFACE

had worked with the poor for many years. Second, participants gave the public meetings serious consideration, taking time to discuss topics of importance that had a profound impact on Medicaid recipients. Third, what interviewees told us privately echoed what we heard in the public discourse. Finally, it was not just one group that appeared dominant and persuasive in the public meetings, nor did anyone mention that one group had persistent power over the process. These reflections led us, on the one hand, to be impressed by the advisory board process as a place for genuine discussion about the design and implementation of an important public policy, and to wonder whether this was an example of a productive inclusive participatory process. On the other hand, another finding created a huge hole in this otherwise pretty picture. The topic of unequal access, which has been a persistent problem in the Medicaid program since it was enacted in 1965 and which Medicaid reform was supposed to address, was raised repeatedly in our private interviews but rarely discussed in the public forum. When we first landed on this finding, we pulled out the common arguments from our back pocket to explain what we found: Public silence and suppression is due to political inequality and exclusionary processes. But the pieces just didn’t fit the puzzle, and it nagged us. This started us on a trail of trial and error, of working and reworking ideas and arguments to find the pieces to this central puzzle. On the way, we vacillated between thinking this was the best research process (to collect data, find an unexpected puzzle, and then search with an open mind for an understanding) and the worst research process (to have an unexpected puzzle rather than a predetermined research question and to pull in multiple disciplinary perspectives rather than drawing from one main body of knowledge). This book is the result of that nagging puzzle and our persistent searching. We draw connections between literatures not often brought together to show the importance of opening up the explanatory picture to answer real-life problems. As happens in the course of most good research projects, we learned a lot along the way, but if we’re honest, it was also a painful process, not just because it took a long time but also because we often found ourselves walking into canons of thought with which we were not familiar. For example, it took us five years to figure out that nonprofit organizations and the role they play in representing the poor in U.S. communities was an important and central part of our story. Thus we have many people to thank for helping us find these connections.

Acknowledgments

This project started when we were at Yale University, where Bradford Gray, director of the university’s Institute for Social and Policy Studies at the time, encouraged us to examine the implementation of Medicaid managed care in Connecticut. Members of the Robert Wood Johnson Foundation’s Scholars in Health Policy Research Program and participants in the Institute for Social and Policy Studies’ health policy seminar provided us with excellent feedback on early conceptual thinking and research design ideas for the project. Theodore Marmor, Jerry Mashaw, Michael Gratz, and Alvin Klavorak were tough critics who helped steer us clear of early pitfalls. Scholars in the Health Policy Research Program provided the necessary blend of constructive criticism and encouragement that helped us launch and stay with the project. We would particularly like to acknowledge the support of Cathy Cohen and Karl Kronenbusch. Mark Schlesinger, also at Yale University, deserves special thanks not only for his willingness to provide extensive feedback and criticism of very high quality but also for his generous support of our scholarship and his genuine friendship. We also offer our profound thanks to the one hundred individuals from Connecticut’s Medicaid policy network who agreed to be interviewed for this project. These individuals, including members of the Connecticut Medicaid Managed Care Council, the Connecticut Children’s Health Project, experts from several states, health care providers, and Medicaid advocates, shared with us precious time and valuable insight. Without their cooperation, this book would not have been possible. Master’s degree students from Yale’s Department of Epidemiology and Public Health provided able research assistance coding the transcriptions from the interview data. Two of the world’s best mentors, Jim Morone and Deborah Stone, encouraged us to rethink our conceptual frames, to go back to the drawing board. Their enthusiasm for the project actually made the prospect of starting over enjoyable.

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ACKNOWLEDGMENTS

At the University of Chicago, Larry Lynn and Michael Sosin pushed hard on some basic assumptions at a seminar, and Larry wrote extensive comments on draft chapters. We have to credit Larry for pushing us to look for alternative explanations for our findings. The late Iris Young, who gave so generously of her time and intellect, provided helpful comments about different forms of deliberative processes and pushed us to think more concretely about where our case fits in the political landscape. Edward Lawlor, while dean of the university’s School of Social Service Administration, read and provided many useful comments on several chapters. Finally, Steve Smith from Washington University provided important advice about the nonprofit advocacy literature, and Jennifer Mosley gave us helpful comments on an early draft of the nonprofit advocacy chapter. Michael Ames helped us to realize the repetition in our early draft and reminded us to “get to the point!” The stellar feedback of Lawrence Brown, from Columbia University, allowed us to see the need to rethink our expectations for deliberative forums. Two anonymous reviewers for Georgetown University Press provided very helpful comments and suggestions. We also want to thank the Public Policy Series editors, Gerard Boychuk, Karen Mossberger, and Mark Rom, for their encouragement and for keeping us on track with the central thrust of the book. Gail Grella, the acquisitions editor, has been an enormous pleasure to work with, and we especially appreciate her ability to expeditiously see the book through the review process. We believe the book is much improved due to the input of all these generous colleagues and friends, but of course we take full responsibility for any limitations or errors of commission or omission. Moreover, we hope those of you not mentioned by name will forgive our oversight. We thank Yale University’s Institute for Social and Policy Studies for a seed grant to cover transcription costs. The Robert Wood Johnson Foundation Investigator Award in Health Policy Research covered a portion of Colleen Grogan’s time on this project, and a portion of Michael Gusmano’s time was funded by the foundation’s Scholars in Health Policy Research Program. The views expressed in the book, however, imply no endorsement by the Robert Wood Johnson Foundation.

ACKNOWLEDGMENTS

xiii

Colleen Grogan. The faculty in the Health Policy Division at Yale University—most notably, Betsy Bradley, Sam Chauncey, Sally Horwitz, and Jody Sindelar—provided intellectual stimulation, encouragement, and good cheer. I had my first child while at Yale, and the support the faculty gave me at that time still warms my heart. I must mention Betsy Bradley as my ultimate role model for combining work and family life. Sarah Phillips was a good friend at Yale and I still miss her humor. I also thank Donald Green for providing office space at ISPS and my other supportive colleagues there, especially Eric Patashnik and Cathy Cohen. I thank Jeanne Marsh, dean at the University of Chicago’s School of Social Service Administration, for her persistent support. Faculty at the university who helped “see me through” more than they know include Beth Angell, Sharon Berlin, Robert Chaskin, Mark Courtney, Waldo Johnson, Judith Levine, Harold Pollack, and Tina Rzepnicki. Several other faculty in the university’s health policy community, especially Kate Cagney, Larry Casalino, Will Manning, David Meltzer, and Diane Lauderdale, have also been helpful and supportive colleagues. I must give special thanks to my sister and sister-in-law, Katie Pulvino and Sue Grosse-Macemon, the two women I rely on most, for all the fun and good times and unwavering support. I owe an enormous debt to my husband, Michael Grosse. We have as equal a relationship as I can imagine. He sometimes jokes that marriage is all about keeping score. Of course, success lies in knowing one’s partner will be there to help no matter what the score is that day. It’s impossible to thank him enough for that. I thank our three daughters, Adelaide, Eleanor, and Clara, for putting up with the weekend days and nights that Mom had to work. But I thank them more for all the wonderful diversions of family life. Finally, I dedicate this book to my mother, Geraldine Grogan Wendt. Although it took me years to realize it, she was my first working mother role model. Thanks, Mom, for all the precious lessons and support throughout the years. Michael Gusmano. After finishing my tenure as a Robert Wood Johnson Foundation Scholar in Health Policy, Bradford Gray and Mark Schlesinger hired me to work on a two-year research project at Yale University, thus allowing me to remain in New Haven and complete

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the empirical work on this project. When I left Yale to join Brad as a member of his staff in the Division of Health and Science Policy at the New York Academy of Medicine, he continued to support my work on this project, and my colleagues at NYAM, particularly Dennis Andrulis, Sara Collins, Gerry Fairbrother, and Heidi Park, taught me a great deal about the implementation of Medicaid managed care around the country. The enthusiasm and support for this book shown by Victor Rodwin of the World Cities Project at the International Longevity Center–USA never wavered. Every few months he would look at me and say, “You simply must publish that book with Colleen!” Well my friend, here it is. Dr. Robert N. Butler and the entire staff at the International Longevity Center–USA, including Everette Dennis, Ken Knapp, Charlotte Muller, Oleg Volkov, and especially, Dan Weisz, provided me with great opportunities, a community of valued colleagues and friends, and a fantastic venue in which to pursue my work on health and social welfare policy in the United States and abroad. As a member of the faculty of the Department of Health Policy and Management in Columbia University’s Mailman School of Public Health I’ve enjoyed the help and support of Allison Evans Cuellar, Tom Ference, Sherry Glied, Fred Hyde, Kim Isett, Peter Muennig, Matt Neidell, Michael Sparer, Jeanne Stellman, and Josh Zivin. I don’t know how to begin to thank my wife, Katie, my son, Joseph, and my daughter, Alexandra, for their support during the long process of completing this book. Katie is my best friend, and our children are a joy. Thanks to them, I’m the luckiest person I know. Finally, I would like to dedicate this book to the memory of my advisor, mentor, and friend, Dr. Linda Faye Williams. As my professor at the University of Maryland, Linda pushed me to think creatively about the relationship between public policy and democracy. Her tireless dedication to social justice, decency, human rights, and better public policy inspired this work.

Introduction

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1 The Problem and Puzzle of Public Silence

Although

the United States has the most expensive health care system in the world and offers a plethora of advanced medical technologies—many of which are life saving—there are many reasons advocates fight for improved health care services for the poor. Compared with higher income Americans, the poor are much less likely to receive preventive health care services and more likely to be diagnosed at a later stage for chronic and terminal illnesses, making the course of their illness more difficult and the probability they will die from their disease more likely (Idler and Kasl 1995; Case and Paxson 2002; Newacheck et al. 2003; Goodman 1999; Case and Paxson 2006; Bradley, Given, and Roberts 2002; Lannin et al. 1998; Merkin, Stevenson, and Powe 2002). Take Chris, for example, the director of a child health advocacy organization who has fought long and hard to improve health care services for residents in her impoverished community.1 When the state of Connecticut began discussing a major reform in the delivery of health care services for poor families under its Medicaid program, it was not surprising that Chris was involved in public discussions about the policy reform, as she put it, from “the very beginning.” Indeed, the Medicaid program plays a crucial role in providing health care services for the poor—it is now the largest health care program in the United States, covering more than fifty million people nationwide. Although Medicaid is an enormous help for many vulnerable people in the United States, concerns continue about the quality of care provided, the availability of providers and facilities to take care of the poor, and the escalating costs of the program. To address these concerns, several states in the early 1990s moved to reform their Medicaid programs by relying on managed care.

4

INTRODUCTION

In 1996, Connecticut followed suit, terminating its fee-for-service (FFS) system for poor mothers and children in favor of Medicaid managed care. Whereas the state used to pay providers directly for health services rendered to Medicaid-eligible patients, it now pays health maintenance organizations (HMOs) a fixed monthly amount to provide health care services to poor, Medicaid-eligible families.2 Sitting in the common area at her community-based organization, Chris expressed great concerns about the fairness of this reform for poor families. Foremost on her mind was the unequal access to providers between poor Medicaid recipients and private-paying “middle-class” members of HMOs. “They want [private physicians] to come into [the Medicaid program], but they don’t try to provide some incentives,” she said. “That’s well and good, but [Medicaid recipients] really think that they’re getting a Blue Cross network [of physicians to chose from] and they’re not. And so there’s this whole illusion that somehow or another, by having a Blue Cross card, there’s going to be more access. And that’s really not the case.” Later, when this issue came up again, she said, “So the HMOs actually only have apartheid care. They have a set of providers for the mainstream population and a different set of providers for the Medicaid population who are in the same health plan. So they created like a special division. Two layers.” Despite Chris’s concern about inequitable access, she never raised the issue in public discussion, even though she had ample opportunity. In 1994, when Connecticut’s Department of Social Services (DSS) began planning its Medicaid managed care (MMC) reform, many providers and advocates for poor families expressed concerns about whether this reform would improve the quality of care provided to Medicaid patients and whether access to health care services would improve. In response, the Connecticut General Assembly still gave DSS authority to submit a waiver to the federal government to implement its MMC program, but it called for the creation of a twenty-sixmember Medicaid Managed Care Council (MMCC) to advise the Department of Social Services on the design and implementation of the new program (Public Act [PA] 97-272; CGS Sec. 17a-127). The law required the MMCC to be composed of the chairman and ranking members of the joint standing committees of the general assembly having “cognizance of matters related to human services and public health, or their designees” (PA 97-272; CGS Sec. 17a-127). The directors of the Commission on Aging and Commission on Children, or their designees, were also required to sit on the council.

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5

In addition, two representatives each from the Department of Social Services, the Department of Public Health, and the Department of Mental Health and Addiction Services were to be appointed by their respective commissioners. Finally, the law required the speaker of the state house and the president pro tempore of the state senate to appoint the remaining members. These had to include two community providers of health care, two representatives of the insurance industry, two advocates for persons receiving Medicaid, one advocate for persons with substance abuse disabilities, one advocate for people with psychiatric disabilities, and two current recipients of Medicaid. The MMCC created four subcommittees to focus on different aspects of the MMC program. In addition, the state created the Children’s Health Project to oversee the provision of health services for Connecticut’s children (making sure children were receiving preventive care and needed immunizations, for example). The Health Project created the Children’s Health Council (CHC) to discuss concerns and offer comments and ideas to help assure that Connecticut’s MMC reform would provide quality health services to the state’s poor children. Each of these groups—the MMCC, its four subcommittees, and the CHC—included representatives of the poor, advocates for the poor, representatives of community-based organizations (who also consider themselves advocates for the poor in their community), representatives of providers groups that take care of Medicaid enrollees, representatives of relevant state agencies, and representatives of involved HMOs. Chris was a member of the MMCC, its access subcommittee, and the CHC. She attended at least three meetings a month to discuss this health care reform program. Some participants attended the meetings of only one of these groups (the quality assurance subcommittee monthly meetings, for example), others attended at least five meetings a month. All participants agreed that there was ample opportunity to raise concerns about the program. And yet the issue of unequal access, which many participants mentioned to us privately as their main concern, was largely absent from the policy agenda. The few times it was raised in these public forums, it was dropped quickly from discussion. Indeed, although the majority of participants raised the issue in our private interviews, and improving access to mainstream providers was a stated goal of Connecticut’s reform program, only a few people raised this concern over an eighteen-month period of public discussions. Why?

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INTRODUCTION

This book intends to answer that question. The most logical and common explanation for why people suppress their views in public, even when given the opportunity to express them, is that they lack political power. Many different literatures speak to this central problem of inequality: scholars writing about participatory democracy have long discussed this problem of inequality and the lack of equal political voice; those concerned about nonprofit organizations’ political activity as an important form of civil society worry about the problem of resource dependency on government funds and whether that dependency mitigates their ability to advocate; and the literature on political agenda setting addresses this issue indirectly by considering what factors influence whether certain policy issues and topics reach the agenda or not. Our central argument is that the key to understanding the problem and puzzle of public silence is to draw from each of these disparate stories. One cannot turn to only one theoretical tradition—either policy agenda setting or resource dependency—to understand this puzzle. Rather, the two together provide a full picture of why there is public silence around a topic of great concern. We found that participant assessments of whether any policy action was attainable around a particular topic determined whether that topic received sustained public discussion. Three interrelated factors influence participants’ assessment of whether any actionable steps can be taken to address their concerns around a particular problem: political feasibility, a ready policy solution to the problem, and data availability to better understand the problem. Yet although participants’ assessments of policy attainability are an important determinant of public talk, it is only a partial explanation. Levels of resource dependency among nonprofit advocates, their political activity, and their social interactions within the policy network provide the other crucial explanatory piece to the puzzle of public silence. In particular, the other main reason for public silence is because this reform policy represented a significant shift in the contracting regime—from collaboration to competition—and this seriously compromised nonprofit advocates’ ability to act as representatives of the poor. Increased political activity on the part of nonprofit advocates in response to this policy reform came with costs to the public voice because it revealed a strong alliance with nonprofit service providers, who were now a politicized group with significant financial interest in the policy reform. Thus even Medicaid advocates with no financial interest had difficulty legitimately criticizing the equal access part

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7

of the reform policy because others perceived their motivations as partisan, political, and aimed at wanting to maintain the status quo. Moreover, strong social ties across competing groups in the network dampened public voice because social interactions led to apprehensions about offending colleagues in a public forum and participants were less likely to raise concerns. In chapter 2 we detail the relevance of these disparate literatures (from deliberative democracy, agenda setting, and nonprofit advocacy) and then show, in the empirical chapters (4 and 5), how each story provides important explanatory pieces for understanding the broader puzzle. But first we consider why it is important to understand the problem of public silence.

THE VALUE OF UNDERSTANDING PUBLIC SILENCE The great promise of democracy is that the state can be ruled by “the people” when they freely engage in multiple types of political action. For example, they can openly discuss their views, protest against a law they disagree with, attend town meetings to discuss a policy proposal, and safely vote for the candidate of their choice. Because an active citizenry is the central ingredient to a wellfunctioning democracy, there is cause for concern when citizens are inactive. Just as there are many ways for citizens to be politically active in an open society, there are many ways to be inactive. Some people choose not to vote, others never contribute or join interest groups that might represent their views, others may never attend a town hall meeting, and still others may participate in public meetings to discuss policies or programs that impact their lives (with the PTO at their child’s school, for example) but choose to voice only some of their concerns. It is this latter form of inaction—the choice to not raise or discuss an issue you care about—that is the focus of this book. However, a critique that potentially undermines the significance of this focus comes from Mackie (1998), who argues that public silence should be accepted as a legitimate expression of underlying preferences. In other words, Mackie and others (Crawford and Sobel 1982; Ross 1995; Elster 1998) argue that just as individuals can misrepresent their preferences through strategically trading votes and bargaining, so too can individuals misrepresent their preferences through deliberation by what they chose to say and not say in a public forum. Thus one

8

INTRODUCTION

should view this form of political inaction as a legitimate form of political action, and there is no need for concern. In contrast to this view, we argue that it is important to understand why participants decide not to raise issues of concern in public forums. For example, if representatives of the poor decide systematically to remain silent about particular types of issues because they feel they must suppress a private concern in public, this is an important problem for democracy. It diminishes the potential for wide-ranging societal benefits, which can be grouped into five main categories. First, deliberation may not change individual opinion, but it may create a greater understanding, and with this, more tolerance for opposing views (Gutmann and Thompson 1996; Walzer 1983). Second, through the process of discussion, deliberation can encourage a public-spirited way of thinking about social problems. Through the process of exchanging ideas and beliefs, individuals may begin to think about their community, or their state or country, and not just their own self-interest (Gutmann and Thompson 1996; Macedo 1999). As political theorist Hanna Pitkin says about a public-spirited way of talking, “It forces us to transform ‘I want’ into ‘I am entitled to,’ a claim that becomes negotiable by public standards. In the process [of making such claims] we learn to think about the standards themselves, about our stake in the existence of standards, of justice, of our community, even of our opponents and enemies in the community; so that afterwards we are changed” (quoted in Eliasoph 1998, 347).3 Third, deliberation helps participants clarify and refine their own positions on issues. Public discourse matters a great deal for how we frame public problems and determines the range of solutions we may consider for addressing problems. How concerns are voiced helps determine how we respond to them, and whether concerns are voiced at all largely determines whether we ever do anything about them (Schattschneider 1975; Gaventa 1980; Pitkin 1967; Eliasoph 1998). Thus discussion may offer new solutions, and lack of discussion may preclude certain worthy solutions.4 Fourth, some deliberative theorists suggest that deliberation could help societies correct past mistakes (Gutmann and Thompson 1996). The hope is that through deliberation, participants will learn about the consequences of implemented policies and the reasons for past failures. Through the course of discussion, participants will present solutions that steer away from past mistakes. Sunstein (2003)

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9

argues, for example, that a host of policy mistakes throughout history might have been avoided if those involved in the process had expressed their reservations publicly. One of the most striking examples is from Arthur Schlesinger’s account of the Bay of Pigs fiasco during the Kennedy administration. Some of Kennedy’s adviser’s entertained private doubts about the action, but according to Schlesinger they “never pressed, partly out of fear of being labeled ‘soft’ or undaring in the eyes of their colleagues” (Sunstein 2003, 3). Another line of reasoning is that deliberation could lead to more just outcomes. It is widely accepted that social and economic inequality leads to political inequality because certain groups are socially and economically excluded and marginalized. As discussed in the beginning of this chapter, the poor and minority groups are significantly underrepresented in the U.S. political system. In light of existing political inequality, Iris Young (2000) discusses how deliberative democracy could be used to widen democratic inclusion and break the cycle of political inequality by uncovering more just policies. Finally, regardless of whether the policy outcome is more just or corrects past mistakes, theorists also argue that decisions emerging from an open and inclusive deliberative process, where all individuals can freely voice their concerns, should be considered more democratically legitimate (Gutmann and Thompson 1996; Elster 1998; Young 2000) than a more closed decision-making processes. These potential benefits of deliberation map closely with arguments presented by Cass Sunstein for why we should encourage dissent and the voicing of concerns. Clearly, we have no guarantee that these benefits will emerge if participants do provide public dissent or voice their great concerns, but Sunstein reminds us of the dangers associated with its absence: “The problem is that widespread conformity deprives the public of information that it needs to have. Conformists follow others and silence themselves, without disclosing knowledge from which others would benefit” (Sunstein 2003, 6). Recognizing the importance of dissent does not suggest that all voices should have equal say over matters of actual policymaking. Dissenters are not always right, and those who support the majority opinion are not always wrong, but by encouraging people to share their knowledge and ideas freely, all participants involved in the public discussion will benefit, even if they decide to reject the dissenting views.

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INTRODUCTION

The literature on the potential benefits of public deliberation, and even the simple voicing of concerns, is plentiful and convincing enough to merit our study, which seeks to understand why public silence occurs. Based on this understanding, we offer some ideas, in the concluding chapter, about how the problem of public silence might be avoided. However, we want to be clear from the outset that we do not have any evidence to argue that the policy outcomes of the case we studied would have been different if the public discussion had been different. As noted in the literature reviewed above, the value of public discussion—greater tolerance, more knowledge and understanding about an issue, the beginning construction of a social problem—is much more subtle and difficult to measure than an obvious change in public policy. Nonetheless, although we offer conjectures in the concluding chapter about the possible consequences of the public silence we observed, our views are simply that—conjectures. We cannot prove that the lack of public talk created specific problems or that public voice would have led to different outcomes. For those of us, however, who already believe that the encouragement of public voice, especially about issues of concern, is helpful—if not necessary—for a healthy democracy, this book has much to offer. It begins to unravel why people suppress their concerns even when given the opportunity to express them.

OUR CASE Although we have provided an argument above for why the study of public discourse is important, we have not yet addressed why it is important to study public discussions emerging out of advisory boards (and their subcommittees). Our answer to this is twofold. First, advisory boards are very common in U.S. politics. Federal agencies have more than one thousand advisory committees in operation (Balla and Wright 2001, 802), and although we are not aware of any formal estimates, causal observation suggests that advisory committees are equally common at the state and local level (Berry and Arons 2003). Because of their common use it is important to understand the potential of public conversation that might emerge from them. Second, contrary to the suggestion of most studies evaluating advisory boards, we argue that these public forums may offer reasonable settings for participants to speak openly about issues of concern. Many studies have dismissed advisory committees as a genuine form

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of participatory democracy. Sherry Arnstein’s (1969) classic study of citizen participation in the Model Cities program suggests that advisory boards represent a form of tokenism and are mostly symbolic gestures designed to avoid pressure for real policy change. Similarly, Simonsen and Robbins (2000) argue that advisory boards are predominantly used by local government to inform decision makers of the views of local experts and that therefore such boards have a low level of political power because decision makers are not forced to act on the board’s recommendations (see also Brenner 2001; Callahan 2000). In contrast to citizen-run advisory boards, advisory committees attached to bureaucratic agencies that include able representatives from specific interested groups have been shown to play a valuable role, particularly when they are used to ensure the responsiveness of the bureaucracy to its intended target population or to the intent of the legislature. A number of “public choice” scholars in political science, including McNubbins, Noll, and Weingast (1987, 1989) and Krehbiel (1991), argue that advisory committees are helpful to maintain congressional control of the federal bureaucracy. Balla and Wright provide some empirical evidence for this claim. They examine the role of the National Drinking Water Advisory Council, an advisory committee within the Environmental Protection Agency (EPA), and conclude that this committee helped to communicate the views of groups represented during the legislative process to the EPA (Balla and Wright 2001). Although these findings are important, we are interested in evaluating a rather different aspect of advisory boards—the content of public discussion that emerges out of their public meetings. Some might argue that the tokenism aspect of advisory boards would lead to artificial public talk. On the other hand, one could argue that because participants play an advisory role, rather than a decisionmaking role, they may act less strategically in their talk and feel more open and free to discuss topics of concern. Moreover, because advisory boards, as compared to more general citizen boards, are attached to specific policies or a particular program, the members and participants of subcommittees are often active in various facets of the policy and therefore may be more motivated to discuss topics of concern. The point is, we really do not know, a priori, whether advisory boards offer an artificial or genuine environment for public discussion. Because advisory boards are such a common institution in our

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INTRODUCTION

efforts to create participatory processes in the United States, and yet little is known about public discussion in these settings, our study can begin to shed some light on the kinds of public talk that emerges. Ideally we would study public discourse in one policy domain across a range of various advisory committees to help us understand whether our findings are unique to our particular context or whether they represent systematic findings across advisory boards. However, as we detail in the methods section below, to adequately unearth what topics are discussed and how in public settings, and to understand how participants think about these relevant topics, it was necessary to conduct participant observation research and indepth, in-person interviews. Given this level of intense fieldwork, which consumed about four years of research time, it was only feasible to explore these questions for one advisory council and its related subcommittees. An important concern, then, for our study is to document that Connecticut’s Medicaid Managed Care Council is not unique but similar to Medicaid advisory councils in other states. We turn now to a discussion of Medicaid policy and recent state Medicaid reforms.

MEDICAID POLICY AND STATE MEDICAID ADVISORY BOARDS Just in terms of size and scope, Medicaid is one of our most important social welfare programs. It is a jointly financed program between the federal government and the states designed to provide health care coverage to low-income Americans. Most people are surprised to learn that Medicaid is our nation’s largest health insurance program. By 2002 the number of individuals covered by Medicaid, our health care program for “the poor,” surpassed Medicare, our universal program for the elderly. Medicaid has about fifty-one million enrollees compared to Medicare’s forty-one million, and it is almost as expensive as Medicare. A few other statistics make its importance crystal-clear: Medicaid covers 20 percent of the nation’s children, pays for more than one in every three childbirths, covers two-thirds of the elderly residing in nursing homes, helps more than six million elderly pay their Medicare premiums and prescription drug costs, and pays for the bulk of services provided to AIDS patients as well as half of all states’ mental health services (Mayes

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2004; Center for Medicare and Medicaid Services website, www. cms.hhs.gov, February 2003). As a result, Medicaid reform is a topic of utmost importance. Beyond scope and size, however, Medicaid policy is crucially important to state governments because access to health care services fulfills one of our most basic needs. When an acute illness or the onset of chronic illness occurs, one can rarely think of a more important service than a skilled compassionate health care provider to help provide a cure or relief from the pain and suffering often associated with illness and chronic disease. Due to the high cost of medical care in the United States, low- and even middle-income Americans are finding it increasingly difficult to get the care they need (Swartz 2006). Although our Medicaid program is supposed to provide health insurance to the poor, and it does cover many poor and low-income families, it also leaves many needy people outside of the system (Grogan 2006). Over forty-five million Americans continue to live without health insurance (Swartz 2006). Many states have turned to their Medicaid program in an effort to expand coverage to these uninsured Americans.5 Yet because Medicaid is already the largest health care program in the United States, these expansions remain extremely difficult for states, especially those states facing budget deficits. Moreover, Medicaid already consumes a substantial proportion of states’ budgets (National Governors Association 2005). For all these reasons, Medicaid reform is top on the agenda in all states. In only a six-month period, from January to June 2006, eleven states received approved waivers from the federal government and another ten states had proposals and plans active in their state legislatures to enact major Medicaid reforms. Among the remaining states, many have already enacted and are in the process of implementing major Medicaid reform, and others have set up an advisory board or commission to discuss reform.6 Many of these reform plans include efforts to expand coverage to more uninsured families but openly discuss the need to set limits in some way. The most popular cost-control approach among the states, starting in the early 1990s and continuing today, is Medicaid managed care, where Medicaid recipients are required to sign up for an HMO.7 Georgia and Indiana are recent examples of states moving to mandatory participation in Medicaid managed care; however, even by 1995 almost all the states had tried some version of managed care. The goal of Medicaid managed care reforms is to not

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INTRODUCTION

only improve access and quality but also control costs by contracting with HMOs to better manage and monitor the care recipients receive. Other state Medicaid reform plans include explicit restrictions on the benefit package. Florida’s recent Medicaid reform legislation provides an example of this approach. Such benefit restriction approaches are in line with provisions passed under the federal Deficit Reduction Act (DRA) of 2005 in which states were given more flexibility regarding Medicaid benefits and cost sharing, including providing benchmark coverage to certain populations rather than full Medicaid benefits. With this increased flexibility, under DRA, come difficult decisions about how to set limits and for whom. The important commonality among all Medicaid reform efforts is the acknowledgment that explicit trade-offs must be made. Do we expand eligibility to Medicaid coverage or expand access to more providers for those who already have coverage? If we expand coverage, to whom? Should the state move toward universal coverage, as Massachusetts is currently attempting? If so, how should the state control expenditures under such an expansion? Should the state contract with private insurers, as they did under Medicaid managed care? Should the state cover more people but restrict benefits? States have to answer these questions, but they will make trade-offs in very different ways. Clearly there is no magic formula for states to follow. These are questions that only our fundamental values can help us answer, which is why the questions of who decides and how are so paramount. Indeed, because these health policy questions, especially those having to do with benefit coverage and provider reimbursement, are so ethically difficult and can be technically complex, many states seek answers to these questions by creating advisory boards (or councils) where diverse points of view are allowed to be heard, discussed, and debated. In looking at all the state’s Medicaid websites, we were able to identify some type of an advisory board or Medicaid commission in every state. Participation on Connecticut’s advisory board and various subcommittees included representatives from the following invested stakeholder groups: Medicaid consumers, Medicaid advocates, Medicaid providers, representatives from participating HMOs, representatives from various state agencies, and members or staff from the state legislature. Because the structure of Medicaid managed care (the contracting approach with HMOs) is essentially the same across the states, the central stakeholder groups

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are the same, and are similarly represented on state Medicaid advisory boards. Moreover, the central purpose presented on state Medicaid advisory board websites is similar: to encourage discussion and deliberation of interested groups’ concerns, questions, and ideas about the state’s Medicaid managed care reform. Although the federal government requires (under 42 CFR 431.12) that states have an advisory committee to the Medicaid agency director, most states have gone beyond this requirement and have independently set up advisory boards and Medicaid reform commissions. For example, when Florida recently passed legislation (Senate Bill [SB] 838) to implement a pilot test of a “defined contribution” plan, they also mandated the creation of an advisory board to oversee the design and implementation decisions associated with this controversial plan. Similarly, Missouri created the Medicaid Reform Commission to help the state decide how to control Medicaid costs. And Ohio setup both the Commission to Reform Medicaid and the Medicaid Administrative Study Council.8 In other words, as in Connecticut, these advisory boards are not just token boards set up in response to a federal requirement but boards that emerge out of pressure within states to broaden participation in the decisionmaking process. In sum, although our case study examines the deliberation of one state’s advisory board during 1995–96, the goals for the Medicaid reform in Connecticut and the trade-offs the state needed to consider—control costs, improve access and quality—are as relevant today across the states as they were then in Connecticut. In other words, there is nothing about the Connecticut case that makes it atypical in terms of its advisory board or the central concerns of its Medicaid reform.

METHODS To examine what participants in the advisory board process said in public discussion and chose not to say, and why, we employed a two-pronged approach. In particular, we used a participant observation method to track what topics were discussed and how and inperson interviews with all participants in the process to understand what topics participants cared about. Before detailing the specifics of our approach, we address an important potential criticism of our method: that we inappropriately attribute what participants reveal

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INTRODUCTION

to us in private interviews as their “true” preferences. Just as participants may misrepresent their views in public conversation, they may also misrepresent their views in private conversation. It might be the case that in conversations with an interested academic, for example, people indulged themselves in reflection and speculation, whereas in public conversation such reflection is not a realistic option and participants are forced to speak more concretely. In this case, so the argument goes (Mackie 1998), the public expression reveals post-trade-off preferences, which one could argue are the actual “true” preferences. We concede that whether people reveal their “true” preferences in private or public conversations is unknowable and any particular claim about true preferences is nonfalsifiable. We do not claim that any particular finding represents respondents’ “true” preferences. However, we do argue that a comparison between public and private expressions is useful based on findings from previous literature. Starting with Erving Goffman in 1959, sociologists and political scientists have distinguished important differences between frontstage (i.e., public) and backstage (i.e., private) behavior and interactions. Two recent studies by social scientists, who specifically studied political talk in public and private contexts, also find important differences. In Eliasoph’s in-depth study of citizen volunteers in an American suburb she found: At each step of the broadening of the audience, the ideas shrank. In a strange process of political evaporation, every group fell into this strictly patterned shift in discourse: what was announced aloud was less open to debate, less aimed at expressing connection to the wider world, less public-spirited, more insistently selfish, than what was whispered. Focusing on the remarkably consistent pattern will tell us what Americans consider “public” to be, and why “public” speech is so often less generously open-minded than private. (1998, 15–16)

Harris-Lacewell (2004) similarly highlights the importance of listening to political talk in different contexts. In her case she notes the unique political ideologies that emerge in African American public spheres as distinct from the type of discourse that is found in the white-dominated public sphere. Mansbridge (1980) also, in her classic study of democracy in a small town in Vermont as well as a workplace setting, used this two-pronged approach: observing public talk in the town hall and

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workplace meetings and interviewing participants privately. This approach enabled Mansbridge to conclude that participants sometimes chose not to speak publicly about issues they cared about because they wanted to avoid conflict and feared ridicule. Although the context of our study is very different, the examples cited above highlight the importance of comparing expressed opinions and concerns in public and private settings to better understand why topics are discussed in certain ways, and why some topics never emerge in the public sphere. Participant Observation Connecticut began implementation of its Medicaid reform program on a voluntary basis in August 1995; it moved to mandatory enrollment in two counties on October 1 and expanded to the entire state by February 1996. Our participant observation of public discussions took place from December 1995 to May 1997—an eighteen-month period. In total we attended sixty-seven public meetings: monthly Medicaid Managed Care Council meetings, monthly subcommittee meetings, and monthly Children Health Council meetings. Our level of participant observation varied depending on the meeting attended. The monthly meetings of the Medicaid Managed Care Council and the Children’s Health Council were primarily designed so that only council members and invited guests spoke. On average there were about fifty people in the audience at the MMCC meetings, mostly people who participated in subcommittee meetings and/or who presented concerns at public hearings. At these meetings we were strictly observers. In contrast, everyone could participate in the subcommittee meetings. These meetings were held in relatively small rooms, and all participants sat around a conference table. In these situations we did not want to bias the process by just observing. At the same time, however, we were not active participants (as we might have been absent this research project). For example, we never raised issues of concern that were not already addressed. We mainly answered factual questions to be helpful and offered research assistance—our publicly perceived area of expertise. In-Person Interviews Almost two years after deliberations about Medicaid managed care reform began, we started to conduct in-person, semistructured interviews with participants in the public forums, from July 1996

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INTRODUCTION

through November 1997. The interviews lasted between two and four hours and were taped and transcribed.9 A team of four research assistants coded all responses.10 There were 103 participants, 100 of whom agreed to be interviewed, giving a response rate of 97 percent.11 To maintain confidentiality, we do not list people by name when quoting from the interview data; instead, we list their identification number and group affiliation for the reader to determine whether it is the same or a different respondent quoted. Our purpose in conducting the interviews was to understand, first, why certain issues were raised in public conversation and others were not, and second, to examine the extent to which interviewees’ private concerns matched their public expression. We asked about four main issue areas according to how the concern was invoked in public discussion. However, before we asked about any specific issues, we asked a broad, unprompted question—“What do you consider to be the most difficult challenge facing the Medicaid program in Connecticut?”—to gauge what participants’ greatest concerns were about the policy. We specifically wanted to determine whether participants raised concerns in the private interview that they never raised in the public forum. Then we asked about issues that were briefly raised or invoked but never really discussed to understand why such issues did not receive a greater hearing. Was it because participants did not care about these issues and therefore the lack of public discussion reflected their private beliefs? Or did participants care but find it difficult for some reason to express their views publicly? We also asked about issues that were debated extensively to examine whether the way people expressed their concerns in private matched their public expression. Analyzing Public Discussion Documenting what topics are discussed in public forums is straightforward, but how does one analyze what is missing from public discussion? There are numerous topics that one would not expect participants to address. For example, one should not expect participants in a public forum asked to address the design and implementation of the state’s Medicaid reform to discuss the merits of national health insurance.12 Thus an analysis of what topics are and are not addressed must be conducted around some reasonable expectations for public discussion. We argue that a conservative boundary for public discussion would only consider topics that were explicitly mentioned in the public forum as program goals.

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In addition, we used the interviews to confirm that the program goals, which emerged in public discussion, were also viewed as important program goals by individual participants when asked in private. Because one can reasonably expect participants in public meetings over an eighteen-month period to return to publicly expressed, and privately confirmed, goals for the program, we argue that topics pertaining to these goals represent a fair expectation for public discourse. In contrast, we are not surprised that our participants failed to discuss national health insurance because no one expressed this topic as a relevant goal of the reform in public or during the private interviews. On the other hand, we do ask why participants did not discuss “access to mainstream providers” because this topic was explicitly discussed and documented in early public meetings as a goal of the program and participants told us privately that they were very concerned about the issue. Through a historical analysis of the Medicaid program we are able to show, in chapter 3, how three main goals—reducing program costs, improving the quality of care provided, and improving access to mainstream providers—have been persistent goals, and problem themes, of the Medicaid program since it was enacted in 1965. By also analyzing legislative and program documents during the initial stages of Medicaid managed care in Connecticut, we are able to show how these three program goals were clearly articulated in the documentation and in the public forums, and how such goals naturally emerged out of Medicaid’s history.

OVERVIEW OF BOOK This introductory chapter presents the central purpose of our book, an argument for why it is important to understand public silence, and provides details about our case and methodology. Chapter 2 locates our central argument about why public silence occurs at the intersection of three literatures: theoretical and empirical work on deliberative and participatory decision-making processes, studies describing how nonprofit advocacy is central to participatory processes focused on social welfare policies for the poor at the state and local level in the United States, and studies that consider how topics reach the political agenda. Our purpose in this chapter is to show how these ideas are all relevant to our central problem of public silence. This review allows us then to use these literatures in

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INTRODUCTION

chapters 4 and 5 where we present our findings of public silence and explanations for why it occurred. A political history of the Medicaid program is presented in chapter 3. The purpose of this history is to provide an understanding of why three dominant goals for Medicaid managed care reform emerged. To appreciate the significance of our finding of public silence—that participants involved in the advisory board process did not debate the mainstreaming goal—it is important to understand the dominance and acceptance of that goal throughout Medicaid’s history and during the adoption of Medicaid managed care in Connecticut. Chapter 4 documents what topics were discussed and not discussed and begins, using the literature on agenda setting, to shed light on why. We use data from our in-person interviews to document that most Medicaid advocates, and several others involved in the public deliberations, really wanted the poor to finally have access to private mainstream health providers. Based on our participant observation we then give examples of the public silence: how, despite this central concern expressed privately, participants rarely raised the issue in public forums, and when it was raised, how the topic was quickly dropped. We highlight how some of the common factors that are known to influence legislative agenda setting—political feasibility, a ready solution, and data availability—seemed also to impact what topics are discussed in public meetings at the local level. Drawing from the literature on nonprofit advocacy, concerns about resource dependency, and the influence of policy networks, chapter 5 details Medicaid’s policy network and describes the longstanding integral tie of nonprofits to Medicaid policymaking. We then describe how Medicaid managed care reform represented a huge change for many nonprofit service providers who rely heavily on Medicaid funds from encouraging collaboration with other nonprofit advocates and service providers to encouraging competition. Finally, we document how public silence can be further explained by considering emerging conflicts of interest and longstanding social ties among participants, which made certain topics difficult to discuss candidly. In the concluding chapter, we return to the problem of public silence and consider potential consequences of the silence we observed. We summarize our explanation of why public silence occurred and highlight our contributions to the literature. We then consider the difficult but important question of what might be done to avoid the problem of public silence.

PART I Explanations and Background

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2 Explanations for Public Silence INEQUALITY, DEPENDENCE, AND INFEASIBILITY

When suppression of the public voice occurs under an oppressive state or under very clear power inequities, the problem is deeply concerning but not analytically troubling. The suppression is so clearly due to fears about a retaliating state or some other powerful source that there is no puzzle. Indeed, upon reading in chapter 1 the story of Chris—an able representative with ample opportunity to give voice about an expressed concern who chose not to—some critics, especially those well versed in the literature on participatory democracy, might respond, “Of course, that is an obvious limitation of participatory processes.” Indeed, one might argue that examples of public silence are so pervasive and the problem so apparently a result of inequality and power that there is no puzzle. To address this criticism we need first to briefly review the arguments for and against greater participation and the uses of discussion in participatory processes. THE TWO SIDES OF DEMOCRACY We can all agree that citizen participation in political life is an essential component to any legitimate democratic state. Yet the form that citizen participation should take to achieve democratic legitimacy is hotly contested. For a long time we have thought about our choices as falling into two main conceptual camps: representative democracy versus participatory democracy. As Mansbridge (1980) points out, most American school children learn about representative democracy, in which one citizen/one vote is required, majority rule decides the outcome, and elected officials carry out voter

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interests as appropriately represented. Mansbridge coined this conception of democracy “adversary democracy” because it assumes citizens’ interests are in constant conflict. Others call it “aggregative democracy” because individual citizen preferences are simply added up to obtain the societal preference. Iris Young describes the model this way: Individuals in the polity have varying preferences about what they want government institutions to do. They know that other individuals also have preferences, which may or may not match their own. Democracy is a competitive process in which political parties and candidates offer their platforms and attempt to satisfy the largest number of people’s preferences. Citizens with similar preferences often organize interest groups in order to try to influence the actions of parties and policy-makers once they are elected. Individuals, interest groups, and public officials each may behave strategically, adjusting the orientation of their pressure tactics or coalition building according to their perceptions of the activities of competing preferences. Assuming the process of competition, strategizing, coalition building, and responding to pressure is open and fair, the outcome of both elections and legislative decisions reflects the aggregation of the strongest or most widely held preferences in the population. (2000, 19)

In short, under the aggregative model of democracy, everyone pursues his or her own self-interest—voters and politicians—in a competitive political marketplace. Voting and bargaining within this marketplace determines how individual interests are aggregated (Mansbridge 1980). One of the main concerns about the aggregative model is that individual preferences are taken as given (see Young 2000 for a more thorough review). Under this model, there is neither an account of where preferences come from nor a belief that they can change. Because preferences are assumed to be exogenous to the political process, they are taken as fixed regardless of whether individuals interact with one another or participate in the political process. Under this view, then, democracy is primarily a mechanism to aggregate individual preferences—usually through voting—not a process that also shapes and influences individual preferences. In contrast to the aggregative model, notions of deliberative democracy often rely on citizens convening—not to vote individually but to reason together. Under this model, public opinion should be

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more than the simple aggregation of individual interests; rather, it should reflect decision making by discussion among free and equal citizens. Indeed, at the heart of deliberative democracy is the notion, articulated clearly by Habermas (1984, 1987), that preferences will be transformed through the active exchange of ideas, including not just voicing opinions but also listening. Through the act of engaging and listening, participants can be persuaded and their thinking transformed. Proponents of participatory democracy also argue that decisions based on voting under the aggregative model often result in a biased representation of views. Several studies find that the poor are systematically underrepresented in the U.S. political system (Schattschneider 1975; McConnell 1966; Lowi 1969; Schlozman and Tierney 1986; Verba, Schlozman, and Brady 1995). Of the organizations in Washington, DC, that attempt to influence political matters, less than 1 percent claim to represent the poor (Schlozman and Tierney 1986). Moreover, even the small number of advocacy groups representing the poor cannot credibly claim that their constituency will deliver on election day because those with relatively low incomes and less education are significantly less likely to vote in any election— whether federal, state, or local (Hays 2001). The fact that a sizable proportion of the poor do not vote is a concern given that their policy preferences are significantly different from those of more affluent people who are more likely to vote. The Vanishing Voter Project found, when they asked about the federal budget surplus, that people who said they were likely to vote (and voted in the last election) were more inclined than nonvoters to say the surplus should go to a tax cut, debt reduction, or strengthening social security. Nonvoters are more likely to say it should be spent on domestic programs in areas such as health, education, and welfare (Patterson 2002). Given the systematic underrepresentation of the poor in the U.S. political process, many scholars and activists have focused attention on how to increase political participation among underrepresented groups. The goal of many noble efforts since the Voting Rights Act of 1965 has been to achieve greater representation in elected positions of underrepresented groups. As a result of these efforts, representation of women and minorities in elected positions has increased dramatically since the 1970s. Unfortunately, income inequality has also increased dramatically during this same time period, and economic inequality has translated into continued political inequality.

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Income inequality in the United States has grown at a steady pace since the early 1970s. As measured by the Gini Index, it declined 7.4 percent between 1947 and 1968, increased slowly during the 1970s, and then rose at a rapid rate during the early 1980s. After more moderate growth between 1987 and 1992, income inequality jumped again in 1993 and was “higher during the 1990s than any decade since the end of Word War II” (Danziger and Reed 1999). Yet income inequality pales in comparison with disparities in wealth. The top 1 percent of wealth holders control approximately 40 percent of household wealth, double what they controlled in 1976 (Wolff 1998). Whereas the assets of the top 1 percent have increased to levels not seen since the 1920s, the segment consisting of the bottom two-fifths of households lost 80 percent of its net worth between 1983 and 1995, and the net worth of the median household fell by almost 9 percent, from $54,600 to $49,900 (Miller 1999). Between 1995 and 1998 middle-class families with annual incomes between $25,000 and $99,000 made small gains in wealth, whereas families with lower annual incomes experienced declines. In contrast, during this same period, families with incomes of $100,000 or more experienced a 22 percent increase in wealth (Maggs 2000). The disparities in income and wealth are even more pronounced for racial minorities and women. According to one analysis, “Blacks own, on average, one-twelfth the amount of property as whites, and this gap in net worth continues to grow even in the post–civil rights era” (Conley 1999–2000, 595). In 1995 the median black household had a net worth of $7,400 and financial assets (which exclude the value of owner-occupied dwellings) of only $200. Among Hispanics, the median household net worth was only $5,000, and financial assets were zero (Miller 1999, 48). Women in the United States earn only seventy-three cents for every dollar earned by men and are more likely than men to have incomes below the federal poverty line (Oliphant 2000). The overall rate of poverty has decreased during the past five years, but the poverty rate among women has increased. A recent study by the United Nations found that the United States lags behind other developed countries with regard to gender equality (Winfield 2000). These growing inequities by income, gender, and race have significant implications for how well our democratic institutions respond to the desires and wishes of the American citizenry. These implications

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were recently summarized well by a special task force on Inequality and American Democracy formed by leading scholars in the American Political Science Association: Generations of Americans have worked to equalize citizen voice across lines of income, race, and gender. Today, however, the voices of American citizens are raised and heard unequally. The privileged participate more than others and are increasingly well organized to press their demands on government. Public officials, in turn, are much more responsive to the privileged than to average citizens and the least affluent. Citizens with lower or moderate incomes speak with a whisper that is lost on the ears of inattentive government officials, while the advantaged roar with a clarity and consistency that policy-makers readily hear and routinely follow. (Jacobs and Skocpol 2005, 1)

Although Americans are concerned about great inequities in wealth and income, the majority support at least a certain level of economic differentiation. Scholars studying American views of distributive justice have consistently found that most Americans logically categorize their views as “equal opportunity for all” in the economic domain and “equal outcomes” in the political domain (Hochschild 1981; Verba and Orren 1985; Kluegel and Smith 1986; Miller 1999). Although this belief system is individually rational, it creates what some scholars have called a fundamental contradiction in American political thought because economic competition often trumps our most sincere attempts to achieve democratic equity (Walzer 1983; Verba and Orren 1985). Thus as economic inequality leads to political inequality, a vicious cycle ensues: A political system that excludes the poor and other disenfranchised groups tends to create and perpetuate more unjust policy outcomes (Young 2000). Some argue that a more intentionally participatory process that emphasizes discussion to allow for the full range of diverse views to be heard could help us get out of this cycle (Gutmann and Thompson 1999; Young 2000). Schneider and Ingram (1997) argue, for example, that especially for public policies that target the poor and other underrepresented groups, an inclusive deliberative process may produce greater understanding of more nuanced views about particular policies (see also Fearon 1998, 46). Although juxtaposing the aggregative model and deliberative model helps to clearly understand the differences in underlying assumptions between the two decision-making mechanisms, most

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theorists today acknowledge the limits in both forms of democracy, and yet the necessity for both to coexist. As Jon Elster suggests, the “importance of time in political life implies that, in addition to deliberation, voting as well as bargaining inevitably has some part to play” (1998, 9). Similarly, Mansbridge argues that both “forms of democracy embody worthy democratic ideals, although each is appropriate in a different context” (1980, 4). Thus for deliberative democracy to have any real purchase for real world politics, we should focus rarely, if ever, on the question of aggregative versus deliberative democracy. Instead, following Mansbridge’s lead, we should focus on when and how various democratic forms can most fruitfully assure that all the voices are allowed and encouraged to speak and be heard. Sometimes a private voting mechanism does this best, and other times, depending on the policy question and context, discussion can be fruitful. In this spirit, we turn next to the key criticism of deliberative democracy—public silence due to inequality—and suggestions for overcoming this problem.

DELIBERATION AND THE PROBLEM OF POWER A key critique of deliberative democracy is that power and inequality impede genuine discussion and deliberation over important topics. Simon (1999) and many others (notably Barach and Baratz 1962; Lukes 1974; Gaventa 1980; Handler 1996) point out that power differentials are pervasive in real-world politics and often affect whether subordinate groups feel comfortable voicing issues of concern and sometimes serve to distort the subordinated group’s sense of its interests and capacities. As a result, participatory efforts that attempt to broaden the spectrum of heard views are often thwarted because marginalized groups tend to acquiesce to the more powerful (Barach and Baratz 1962; Lukes 1974; Gaventa 1980; Handler 1996; Simon 1999; Gambetta 1998; Stokes 1998; Przeworski 1998). Under the problem of acquiescence, public deliberation can actually promote conformism—rather than unearthing important “real” differences in opinion—and a false consensus emerges (Stokes 1998; Przeworski 1998). Many deliberative theorists grapple with the question of how public forums and discussion can be structured to reduce public silencing arising from inequality and power differentials. Mansbridge (1980), for example, observed this problem of false consensus in her study

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of citizen participation in a small town in Vermont, where many townspeople chose either not to go to meetings or not to speak up at meetings because they feared conflict and ridicule. She suggested relying on representatives to debate and make decisions when interests are clearly in conflict rather than face-to-face discussions between friends, acquaintances, or neighbors, situations in which participants specifically try to avoid conflict. Gutmann and Thompson (1996) similarly suggest that part of the concern about inequality stems from a fear that subordinate groups are not as skilled at deliberation and will therefore lose out. They argue that this fear can be overcome by the use of able representatives, who speak on behalf of marginalized groups. In Button and Mattson’s (1999) study of seven different public forums throughout the United States, they also observed problems of power dynamics where citizens deferred to technical experts and political leaders, believing the latter had a more informed and therefore more valuable opinion about the topic at hand. The suggestion from their research (though they did not explicitly conclude this) is that able representatives (as opposed to lay citizens) would be useful in deliberative forums because they might not so readily defer to technical experts and elected officials and feel more confident voicing their opinions. Although deliberative theorists provide strong, convincing arguments for the importance of able representatives, they fail to ground the discussion in any concrete way to consider who, in reality, these able representatives of the poor could or should be. Scholars studying advocacy for the poor and the role of nonprofits do, however, provide that grounded discussion.

THE VOICE OF NONPROFITS Political scientists have long argued that social welfare programs for vulnerable people suffer politically in the United States because the poor, disabled, sick, jobless, and frail have no money or organized power to support interest groups to work on their behalf. As discussed earlier in this chapter, there are relatively few interest groups representing the poor in Washington, and such groups play a minor role in lobbying.1 Berry and Arons (2003, 134), however, point out that if we move away from Washington and legislative lobbying and focus instead at political activities and administrative policy making at the state and local level, then we find that significant

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representation for the disadvantaged already comes from the nonprofit sector. Several legislative changes, primarily in the 1960s, significantly increased government reliance on the nonprofit sector to provide important health and social services to the poor. For example, in the 1962 Social Security amendments the federal government changed its approach to providing welfare from largely relying on cash assistance to heavy reliance on the provision of in-kind social services to help some of our most vulnerable citizens (Smith and Lipsky 1993; Salamon 1995, 2002; Boris and Steuerle 1999). Moreover, the creation of Medicaid in 1965 significantly expanded government reimbursement, primarily to nonprofit health care organizations, for health services rendered to the poor (Grogan and Patashnik 2003a, 2003b; Grogan 2006). This growing government reliance on social service provision (e.g., job training, health, community development, day care) transformed the nonprofit sector from “largely a source of private charity to being an arm of the government” (Berry and Arons 2003, 11). Today, these service-providing organizations account for 40 percent of nonprofit organizations and an astounding 80 percent of nonprofit employment. Although these nonprofit service organizations still rely on fees and charges to raise the majority of their income (54%), government funding (through grants, contracts, and reimbursements) is the second largest source of their income (36%) (Salamon 2002). Although the amount of nonprofit reliance on government funding varies by service sector, for some organizations government support is high. Organizations that provide mental health services and/ or drug and substance abuse treatment, for example, depend on government for as much as two-thirds of their funding, and community health centers, which are primary sources of health care for the poor and low-income living in underserved communities, rely on a combination of federal, state, and local government for about three-quarters of their funding (Salamon 2002). Because the United States relies so heavily on the nonprofit sector to carry out government-funded social services, when vulnerable people need help beyond cash assistance, they often go directly to nonprofit organizations and may not even have to interact with the government. For this reason, government often relies on nonprofits to gain an understanding of people living in vulnerable communities. Ironically, as government reliance on nonprofit human service organizations has helped to shape our understanding of

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them as representatives of the poor, nonprofits’ growing reliance on government funding has raised concerns about whether nonprofit organizations are able to remain politically active and to continue their vital role in providing a voice for the disadvantaged (Boris and Steuerle 1999; Grønbjerg 1993; Salamon 1995; Smith and Lipsky 1993; Chaves, Galaskiewicz, and Stephens 2004).

NONPROFITS AND THE POTENTIAL PROBLEM OF GOVERNMENT DEPENDENCE “The concern is that dependence on government for a sizable part of their budget forces non-profits to be too compliant, too ready to do what funding agencies want,” notes Berry and Arons (2003, 104).2 This clearly happens to certain organizations in particular contexts (Chaves, Galaskiewicz, and Stephens 2004). For example, Harris (2001) found a connection between the lack of political activity of some of Chicago’s major African American churches during the civil rights movement and their financial dependence on the city’s Department of Human Services (what Harris termed Mayor Daley’s “patronage”). Several studies report that nonprofit executives are fearful that oppositional political advocacy may be costly: Either their funding will be reduced, referred clients diverted, or they may be excluded from important meetings (Reid and Steuerle 1999; Stone 1996; Berry and Arons 2003; Hudson 2002). Although it is unclear whether (or how often) government funders would actually follow through with imposing such costs, the fear itself may be enough to seriously dampen nonprofit political activity (Chaves, Galaskiewicz, and Stephens 2004). Significant government funding can also encourage nonprofits to reorganize their administrative activities to meet the demands of their government funder. Indeed, along with government funding often comes specific administrative requirements such as creating a database to document outcomes and/or providing financial accounts of activities. Several studies suggest that for many nonprofits, these increased administrative duties may force them to reduce previous efforts devoted to political activities (Alexander, Nank, and Stivers 1999; Froelich 1999; Grønbjerg 1993; Kramer 1981; Smith and Lipsky 1993; Stone 1996). Although many scholars have raised concerns about increased government funding creating resource dependency leading to a

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decrease in nonprofit political activity, others point to the opposite effect, that increased government funding can lead to an increase in political activity. Chaves, Galaskiewicz, and Stephens (2004) provide a useful theoretical model illustrating how increased government funding can create two opposing forces on political activity. They highlight two mechanisms that might result in lower political activity, resource dependency (as discussed above) and tax rules against lobbying, and two mechanisms that might result in increased political activity, monetary self-interest and government dependence on nonprofits. The incentive to increase political activity due to monetary selfinterest is straightforward: “Nonprofit leaders whose organizations receive government funding have an objective incentive to increase their participation in the political process to protect or enhance their own funding streams or otherwise improve their working conditions” (Chaves, Galaskiewicz, and Stephens 2004, 298). Several case studies suggest that this incentive is real and nonprofits with significant government funding devote substantial political effort to enhancing and securing those funds (Kramer and Grossman 1987; Smith 1999; Nowland-Foreman 1998). Monetary self-interest does not necessarily imply that nonprofit interests are not aligned with the interests of their clients. Not surprisingly, most nonprofits believe they can better serve their clients under increased financial resources (Chaves, Galaskiewicz, and Stephens 2004). The second mechanism that can lead to increased political activity comes from the government funder itself. Chaves, Galaskiewicz, and Stephens point out that “resource dependency between government and nonprofits can be a two-way street” (2004, 299). The literature on government contracting has long recognized that, depending on the market, government may be forced to rely on only a few suppliers (Donahue 1989). Indeed, government dependence accurately describes the majority of the contracting arrangements at the state and local levels for vast provisions of health and social services to the poor (Saidel 1991; Kramer and Grossman 1987). For example, Berry and Arons found in their study of nonprofits across the U.S. that “in their role as advocates, most nonprofits have no active opposition. At the state and local level nonprofits working on behalf of their constituents generally encounter few, if any, other organizations offering policymakers an opposing point of view” (2003, 94). Indeed, in his summary of the four main advantages nonprofits enjoy in lobbying city hall and

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state agencies, it is telling that they all (but especially number 3) suggest government dependence on nonprofits: 1. Little in the way of resources has to be devoted to getting a foot in the door—the doors to city government and state agencies are already open. 2. City and state administrative agencies that deal with social service and health care providers do not have to worry as much about showing favoritism and do not have to safeguard their proceedings with as thick a cover of ex parte rules. 3. Without substantial opposition or competition, partnerships with government are possible, if not imperative. 4. Policy initiatives are not typically stymied by lobbying groups pushing for diametrically opposed objectives (Berry and Arons 2003, 97).

Obviously, when government is dependent on nonprofits to provide needed government-funded services, government agencies encourage—indeed, they need—nonprofits to be politically active. Berry and Arons (2003) conducted a survey of nonprofit organizations and found, for example, that 36 percent of nonprofit health care organizations meet frequently with government officials and 57 percent reported that government officials are interested in hearing their views. Under this two-way dependency scenario, the problem of nonprofit dependence on government resources and suppressing oppositional advocacy may not occur. That is, if we take Berry and Arons’s description to heart, one might conclude there often is no opposition and the interests of nonprofits and government are aligned, and therefore there is no need to suppress oppositional advocacy. Most important, Chaves, Galaskiewicz, and Stephens’s model and Berry and Arons’s description of local context, highlight the importance of understanding market context to predict whether increased government funding would lead to decreased or increased political activity. In other words, whether government funding creates problems of resource dependency is most likely conditional on the local political marketplace. For example, one might hypothesize that resource dependency problems are minimal for nonprofits with monopoly power, even if they have a high level of government funding. Chaves, Galaskiewicz, and Stephens (2004) provide a nice test of their theoretical model, but they are unable to capture the local political context. Instead, their empirical model measures the aggregate net effect on political activity. By measuring eight different

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types of political activity among a nationwide study of nonprofit religious congregations and two types of political activity among nonprofits in the Twin Cities (Minneapolis and St. Paul) metropolitan area, they show that government funding is most often positively associated with political activity.3 In particular, the positive and negative forces “net out to either a positive or a null effect on political activity” (314). They note: We are tempted to conclude that government funding in fact enhances nonprofits’ political activity, but a more cautious interpretation of our results is that government funding does not suppress it. Yet even this more cautious interpretation implies that the nonprofit sector remains a viable vehicle of citizen advocacy, even in the presence of its increasing reliance on government funds to carry out its core work. At least in the specific manifestation we have examined, civil society’s capacity for political action does not seem to be reduced by its increased reliance on government funding. (Chaves, Galaskiewicz, and Stephens 2004, 314)

As suggested at the beginning of this discussion on nonprofits, several studies echo the conclusion that nonprofits with significant government funding still remain a viable and important vehicle for citizen advocacy. The two mechanisms discussed by Chaves, Galaskiewicz, and Stephens (2004)—nonprofit self-interest and government dependence—appear to be strong forces toward increased political action. Indeed, there is yet another force coming from local government that increases nonprofit political action. At the same time that government has increased its reliance on nonprofits over the last forty years (Smith and Lipsky 1993; Salamon 2002), there has been a steady push for state and local governments to become more inclusive in their decision-making processes and in their effort to increase citizen participation (Morone 1990; Day 1997; Berry and Arons 2003; Irvin and Stansbury 2004; Bingham, Nabatchi, and O’Leary 2005). Berry and Arons (2003) highlights the specific interaction between participatory democracy and nonprofits at the local level: One of the most conspicuous characteristics of social policy on the state and local level is the citizen participation requirements built into program operations. These federal and state mandates have contributed to the collaborative relationships that have emerged over time between nonprofits and agencies. Although widely

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discredited . . . citizen participation programs have flourished. . . . The easiest and most productive way for city hall to work with neighborhoods is to collaborate with the non-profits that operate there. [We use nonprofits to] incorporate members of the community into public policymaking. In today’s cities, citizen participation is really non-profit participation” (111, 114).

Some argue that, given the structure and mission of most nonprofit service organizations, it is not only convenient but also reasonable to look toward nonprofits to provide community representation, especially for disadvantaged communities (Smith and Lipsky 1993; Berry and Arons 2003). Although various forms of community participation are requirements for government funding, many nonprofit human service organizations already have community participation and community-based programming as a central part of their mission statements. Especially because the poor and disadvantaged are less likely to vote, and are not well represented by the interest group lobbying so common in the U.S. political system, many argue that nonprofits provide an important and crucially needed voice for the poor (Berry and Arons 2003; Smith and Lipsky 1993). Berry and Arons (2003) assert that nonprofit human service organizations essentially act as interest groups for the disadvantaged: “Nonprofits represent their constituents (when) they become active in the political process. Nonprofits speak for, act for, and look after the interests of those they are concerned about” (30). Thus there are many reasons, in support of Chaves, Galaskiewicz, and Stephens’s findings, why government funding of nonprofits would increase nonprofit political activity. However, finding that participation in specific political activities either remains the same or increases does not necessarily mean nonprofits do not, at the same time, suppress certain types of political engagement. Indeed, other, more nuanced studies suggest that while nonprofits remain active, they suppress certain aspects of their advocacy. For example, Alexander, Nank, and Stivers (1999) talked to nonprofit representatives in one county in Ohio using a focus group to analyze the impact of welfare reform (devolution and a contract regime change) on nonprofit advocacy. They found that welfare reform increased nonprofits’ reliance on government funds and substantially diminished their capacity to provide various community outreach programs and advocate on behalf of their client communities. However, they also found that nonprofits maintained political activity by highlighting those programs where they could show the most progress to

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government funders: “Although [nonprofit] representatives would occasionally convey misgivings in private, they believed that agency relationships with the county [government] were too important to jeopardize” (279). Berry and Arons (2003) also found from his interviews with nonprofit representatives that they avoided confrontations with funding agencies, and he concluded that their need to win and retain contracts significantly tempered the aggressiveness of their advocacy. The director of a health care nonprofit bluntly told the Berry research team, “I want to be a good grantee. I want to be a good grantee because I want to continue to be funded. . . . You have to decide where to draw the line where you’re willing to risk your money. We’re going to keep quiet about some things because it just isn’t worth it. But on other things we’re willing to take the risk . . . to take a stand” (106). This quotation, and Berry’s findings in general, raise important questions: What policy topics and issues are worth the risk? Conversely, which issues never get discussed because “it just isn’t worth it”? These are the questions our study attempts to address. Understanding the content of nonprofit advocacy—or the black box of nonprofit political activity as Chaves, Galaskiewicz, and Stephens describe it—is important because although nonprofits may only infrequently choose between their conscience and funding, as Berry and Arons suggest, it might be that they are more likely to compromise, or temper, their advocacy for some issues and not others. To better understand the content of public voice and advocacy, and why some issues never reach public discussion, we turn now to the literature on policy communities and agenda setting.

THE IMPACT OF SOCIAL INTERACTIONS ON PUBLIC TALK Political scientists have long recognized the importance of understanding agenda setting and the policy process. Indeed, Schattschneider (1975) argued long ago that agenda setting—determining what topics reach the political agenda and how they are defined—is the “supreme instrument of power.” For years scholars described the policy process in Congress as a closed “iron triangle” in which key decisions were made between powerful members of congressional committees, heads of executive agencies, and representatives of a few powerful interest groups (Baumgartner and Jones 1991; Gais, Peterson, and Walker 1984; Fritschler 1999; Berry 1989).

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However, coinciding with movements toward more participatory democratic processes at the state and local levels were an increase in the number of national interest groups and reforms that led to a growth in the number of congressional committees. Amid these changes scholars began to argue that public policy could no longer be accurately described as shaped solely by closed iron triangles. New theories about the importance of “policy communities” (Walker 1991), “issue networks” (Heclo 1978), and “government subsystems” in shaping public policy emerged (Baumgartner and Jones 1991; Gais, Peterson, and Walker 1984, 1991; Peterson 1993; Sabatier 1991). The general definition of a policy network is that it “consists of a group of actors who share an interest in some policy area and who are linked by their direct and indirect contacts with one another” (Mintrom and Vergari 1998, 128).4 Much progress has been made in explaining policy development by examining the network of relevant actors—across the public and private sectors and throughout different levels of governance— concerned with a given policy problem (Sabatier 1988; Parsons 1996; Mikkelsen 2006). Although some policy networks can be stable over time and relatively closed, several studies have shown how networks evolve over time and public policy changes consequently occur (Baumgartner and Jones 1991; Birkland 1997; Schattschneider 1975; Sharp 1994). The main distinction, in fact, between these network concepts and iron triangles is that as opposed to a closed, consensual process, policy issues in a network are often contested between multiple competing groups (Golden 1998; Sabatier 1991). The network perspective assumes that policy is continually changing due to changing actors, varying degrees of interaction among actors, and the pattern of relationships within the network (McGregor 2004; Pross 1990). Notable studies by Knoke (1990) and Coleman and Skogstad (1990) examined the relationships between organizations within the policy network and found that policy development can best be explained by understanding the properties of the relationships between actors within the network. Mintrom and Vergari (1998) also studied interactions among network members to understand their impact on the diffusion of policy innovations. They found that such ongoing interactions “permit the formation and dissemination of judgments concerning the character of actors who propose innovations. Consequently, network information about innovations will be tagged with opinions on the reliability and trustworthiness of

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the innovators” (128). This relates to Granovetter’s (1985) notion of “embedded” social networks. He argues that concrete personal relations within networks generate interpersonal trust and social norms. Indeed, Mintrom and Vergari (1998) build on Granovetter’s notion of social norms to understand why certain ideas carry more weight within networks than others.5 They write, “In a welldeveloped network with a robust communication system, actors of poor character and judgment, as well as poorly conceived ideas, are quickly identified and discredited” (128). Although they provide convincing evidence that network members communicate and make judgments about policy ideas and members within the network, it is still unclear why certain ideas are judged to be poorly conceived or why certain individuals are judged to be of poor character. This question is particularly relevant to our case: Why are certain topics discussed in the public forum but not others, and what is the role of network-based social relations? Another strain of research, which focuses on the influence of external factors on policy networks, helps to illuminate this question. Many scholars in recent years have focused on the effect of so-called policy feedbacks. This work describes how new public policies can create new actors in the policy network. These new actors change the constellation of advocacy coalitions and social interactions, which in turn has the potential to change the policy agenda (Baumgartner and Jones 1991; Gusmano, Schlesinger, and Thomas 2002; Mettler 2005; Pierson 2005; Schattschneider 1975; Sharp 1994; Soss 2000; Weir 1992). These studies point to the importance of policy regime changes for understanding shifts in social relations, and the emergence of new ideas and norms, within the policy network. This suggests that to understand why certain ideas carry more weight—and perhaps are discussed more frequently in public forums—it is important to describe the policy network and to examine interactions among network actors. Following this reasoning, we describe the Medicaid policy network in chapter 5, including the importance of nonprofit health and social service providers in the network, and discuss relationships among actors. We document how a major policy shift—Medicaid managed care—changed the constellation of actors and the social interactions within the network, and how particular judgments about ideas and actors emerged. We argue that these judgments influenced what participants in the public forums chose to discuss openly. This is one of our unique contributions: to show how policy reforms can change

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interests within the network, which in turn impacts social interactions within the policy network. These social dynamics influence how network participants are perceived and ultimately which topics they feel comfortable with and can legitimately discuss in the public forum.

THE IMPACT OF INSTITUTIONAL FACTORS ON PUBLIC TALK Although the role of network-based social relations is a vital piece to understanding our puzzle, Kingdon’s (1984) classic work reminds us of the importance of institutional factors for understanding how policies reach the political agenda. He specifies three main streams— the problem, policy, and political streams—and argues that all three must come together for a particular topic to reach the policy agenda and for legislation to eventually pass. Although Kingdon was describing the policy process for the U.S. Congress and how that institution sets the agenda, the broad contours of his model might be useful to understand why certain topics are discussed in public forums at the local level outside of the formal legislative body. In chapter 4 we consider as possible explanatory arguments how three common factors (shown to influence legislative agenda setting)—political feasibility, a ready solution, and data availability— might also impact what topics make it into public discussion. First, similar to Kingdon’s discussion of the importance of political feasibility (actual votes and perceptions of it), we found, based on our interviews, that individual determinations of political feasibility influenced participants’ strategic assessments of which topics were worth their effort to address in public discussions. Second, similar to findings by several other scholars that the enumeration of a problem or the mere presentation of data to describe a problem is a powerful tool to focus attention on a particular issue (Morone 1993; Stone 2001), we find that the presentation of new data turned public discussion toward focusing on the topic the data pertained to, and conversely, the absence of data made it difficult to maintain public discussion on a particular topic.6 Third, the policy stream described in Kingdon’s model is composed of potential solutions developed primarily by experts and advocates working in policy communities. Kingdon discusses how windows of legislative opportunity can quickly close when there is

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no solution to the perceived problem or if the existing solutions are viewed to be politically unacceptable (see also Blumer 1971; Birkland 1997; Linders 1998; Nakamura 1987; Nelson 1984; Spector and Kitsuse 1987). Sabatier’s Advocacy Coalition Framework (ACF) adds an important dimension to the Kingdon analysis. Sabatier (1991) argues that the dynamics of agenda setting are influenced by the nature of the policy community. Within a particular domain, there are usually at least two coalitions that compete over policy decisions. Sabatier argues that policy stability depends on the extent to which it is possible to identify policy solutions that are consistent with the core beliefs of each coalition. We describe in chapter 3 how Medicaid managed care was a popular solution that diffused quickly across the states because it was consistent with the core beliefs of different coalitions within the Medicaid policy network. However, once the reform was implemented and many participants had concerns that this solution was not working well for improving access to mainstream health care, the lack of any alternative solution—combined with the other two factors, political infeasibility and lack of data—“closed the window,” as Kingdon suggests, and made it difficult to discuss the issue in a public forum. In sum, we improvise Kingdon’s model, which explains why some topics get on the political agenda and passed into legislation, to consider how it might help explain why public silence occurred. We argue in chapter 4 that three factors—politics, problems, and solutions—most certainly stymied public conversations around the equal access goal. However, by comparing topics that were discussed to the silenced topic, we are able to show the limitations of this model to fully understand public silence. We find the remaining explanatory pieces by looking at the context of the policy network, how policy reform impacted the interests and relations within the network, which ultimately influenced which topics participants felt comfortable giving voice to.

CONCLUSION In this chapter we reveal the linkages between three different literatures addressing the central problem of public silence. Scholars writing about participatory democracy have long discussed the problem of inequality and the lack of equal political voice and offer more deliberative public forums with able representatives as a

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mechanism to improve the situation. At the same time this literature offers little guidance as to whom these able representatives might be to overcome political inequality. Those studying nonprofit organizations offer help in this regard by pointing out how representatives of nonprofit organizations have long provided able representatives of the poor and are already politically active in participatory decision making at the local level. Although this literature also raises concerns about nonprofit reliance on government funding and whether political advocacy is suppressed, several recent studies find that significant government funding does not on net reduce nonprofit political activity. Our study adds to this literature by opening up the black box of political advocacy by considering the content of that advocacy, at least in public meetings associated with advisory boards. Moreover, by bringing in the literature on policy networks and political agenda setting, we are able to consider how reasons for political suppression may be more complicated than simple resource dependency. In particular, we highlight how institutional factors—political feasibility, lack of perceived solutions, and lack of data—play a role in chapter 4, and we detail the importance of changed interests and social relations within the policy network in chapter 5. But first, in chapter 3, we document the broader context of the Medicaid managed care reform and show how three main goals for MMC emerged out of Medicaid’s political history.

3 Medicaid’s Persistent and Conflicting Goals EQUAL ACCESS, QUALITY CARE, AND COST CONTROL

Despite persistent hopes, the goal of providing the poor access to high-quality, mainstream medical care at reasonable costs has remained elusive for the last forty years, for reasons too large and complex to cover adequately in this chapter.1 Our main intent is to show, despite Medicaid’s failings, how these goals have remained aspirations for the program over time. Interested groups, most notably Medicaid providers and advocates for the poor, often use these stated program goals to hold states, agency heads, and elected officials accountable for program promises left undelivered. Indeed, variations on these same goals were explicitly stated as important aspirations for Connecticut’s Medicaid managed care program. We document the history of Medicaid’s stated goals at the national level over time and then the explicitly stated goals in Connecticut’s Medicaid reform to illustrate that these were not new goals that emerged in one state at a particular point in time but goals held across the nation since Medicaid’s beginnings in 1965. We begin by documenting briefly the rise of dual-track medical care in the United States, where the poor primarily receive substandard care in public clinics.2 This history is important if we are to understand the enormity of Medicaid’s idealistic goals in 1965 to change that separate and unequal system of care. We then show how the federal government, and consequently the states, quickly retreated from these program ideals when Medicaid expenditures skyrocketed unexpectedly. This significant retrenchment created the reality, and the image, of Medicaid as welfare medicine.3 Next we explicate the expansionary side of Medicaid and show how it operates in tension with Medicaid’s recurrent retrenchment policies.

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We argue that specific expansionary seeds imbedded in the origins of Medicaid have enabled advocates to resurrect these stated program goals and to ask at strategic times for a recommitment to equal access and improved quality.

DUAL-TRACK MEDICINE AND MEDICAID’S CURE The history of American health care for the poor is a dismal one. It begins with a concerted effort by government to use institutionalization (almshouses, also called poorhouses or poor farms) as a legitimate method for addressing the concerns of poverty.4 Institutionalization of the poor began with fervor in the 1820s due to a demographic explosion and economic changes that bolstered the view that the causes of poverty could be located squarely within the individual. With this view in hand, the philosophy of almshouse administrators was to change individual behavior through work and punishment (Katz 1986; Holstein and Cole 1996). This view of the causes and appropriate treatment of poverty translated into the medical environment in two main ways.5 First, medical providers were under no obligation to provide services to the poor. There are numerous examples of the poor in medical need being turned away by physicians (Rosenblatt 1975; Rodwin 1995; Watson 1995). Even when this refusal to treat resulted in death, the courts still repeatedly ruled in the provider’s favor arguing, in essence, that medical care is like any other product and the provider should have absolute authority to decide when and to whom she or he would like to sell that product (Rosenblatt 1975; Rodwin 1995; Watson 1995; Hoffman 2006).6 Second, public and private charitable hospitals emerged alongside city almshouses not necessarily to provide good medical care but with its primary purpose being “to protect the healthy, well-off population from the contagiously ill or socially disruptive poor, and to provide teaching material (in the form of patients) for medical education” (Rosenblatt 1975, 644; see also Stevens and Stevens 1974). In keeping with the concept of poverty as deviant, a view predominant in the nineteenth century, hospital care for the poor can best be described as a system of rules that governed patients’ behavior. Expulsion was the usual punishment for infractions, patients performed mandatory labor to compensate the hospitals for their care, and use of poor patients as teaching material was widespread and occasionally brutal (ibid.).

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Although almshouses, which housed the poor of all ages as well as the sick and mentally ill, grew rapidly during the nineteenth century, social reformers at the turn of the century began designing institutions for certain groups of people with reform, rehabilitation, and education in mind. For example, children were sent to orphanages, the insane to mental institutions, and the physically disabled to special schools (Stewart 1925; Rothman 1971; Rosenberg 1987; Katz 1986). Hospitals, which had been perceived as places to die, also were changing and growing in the early twentieth century, becoming places where sicknesses could be cured. Older people with chronic conditions that could not be cured, and the undesirable poor who could not pay to be cured, had no place in these new institutions, however (Stevens 1971; Rosenberg 1987; Vladeck 1980). As a result, nursing homes emerged for older people, and the old county, public hospitals were maintained as separate facilities appropriate for the poor.7 The 1930s Great Depression shifted public opinion about the causes of poverty from questionable individual behavior to forces over which the individual had no control. As widespread unemployment, old age, and unfortunate circumstances such as sickness and the death of a spouse thrust hard-working Americans into poverty through no fault of their own, the public looked to the federal government to help solve the problem of basic economic need (Katz 1986; Stevens and Stevens 1974). The horrendous, inhumane conditions of the almshouses also became more widely recognized. New Deal activists argued that oldage pensions for older people and public assistance for the worthy poor (e.g., widows and their dependent children) would allow such people to live with dignity outside of institutions (Vladeck 1980; Stevens and Stevens 1974). When the federal government passed Old-Age Survivors Insurance (OASI, what we call Social Security today) and federal-state, means-tested public assistance programs— Old–Age Assistance (OAA) for poor, older Americans and Aid to Dependent Children (ADC) for poor widows and children—politicians and administrators made it clear in the statutes that no assistance would be given to almshouse inmates (Vladeck 1980; Holstein and Cole 1996). Such language also was inserted in the landmark Social Security Act of 1935 with the clear intent of closing the poorhouses.

MEDICAL VENDOR PAYMENTS, 1950 After 1935 the states could include the cost of medical care in their determinations of need for public assistance payments (i.e., payments

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for OAA, Aid to Dependent Families [ADF], and Aid to the Blind [AB]), but they were pragmatically constrained by federally defined maximums on payment amounts. Many states argued that the federal maximums were so low that states could not include the “true” costs of medical care, and yet they argued further that it was often sickness and medical care expenditures that then caused poverty (U.S. Congress 1950, Altmeyer testimony; Vladeck 1980; Stevens and Stevens 1974). In an effort to address these concerns, medical vendor payments were created under the Social Security amendments in 1950. This program allowed states, under a separate federal financial matching formula, to pay medical providers directly for services rendered to public assistance recipients (Stevens and Stevens 1974). For the first time, states could set the level and terms of payments to medical providers, including physicians, hospitals, and nursing homes, for public assistance recipients. Moreover, an apparatus was established to begin regulating the quality of care provided to public assistance recipients in such facilities. At the same time the 1946 Hill–Burton Act also provided funds for hospital and nursing home construction.8 The act required grantee hospitals to provide a “reasonable volume of services to persons unable to pay” (Rosenblatt 1975, 645; 42 U.S.C. 291c[c]). Unfortunately, however, neither the surgeon general nor the Department of Health, Education and Welfare (HEW) used their enforcement powers to determine whether, and to what extent, hospitals built with Hill–Burton funds provided charity care to poor people. As a result, though many more private nonprofit hospitals were built during the post–World War II period, their proliferation did little to lessen dual-track segregation (Stevens and Stevens 1974; Rosenblatt 1975). Again, two consistent themes continued: medical providers have no obligation to provide health care to the poor and public facilities are (perhaps consequently) viewed as the appropriate place to provide health care services to the poor.

FIGHTS OVER NATIONAL HEALTH INSURANCE AND THE KERR–MILLS ACT OF 1960 After Truman’s failure to enact national health insurance and in the wake of passing medical vendor payments in 1950, the two camps— those supporting social insurance and those supporting a meanstested, public assistance approach—shifted their positions a bit.

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Proponents of national health insurance decided to restrict their goal of universal coverage to expanding hospital benefits only for OASI beneficiaries—in other words, those age sixty-five and over. Reflecting this new position, Senator Forand introduced the original “Medicare” bill in 1957 proposing universal coverage for older Americans with a restricted, hospital-based benefits package administered and financed on a contributory basis by the federal government (Marmor and Marmor 1970). In response to the Forand bill and mounting public pressure to do something for the aged, opponents of the universal approach, namely, Representative Wilbur Mills and Senator Robert Kerr, proposed a means-tested alternative. This alternative passed in 1960 and came to be called the Kerr–Mills Act. Although the state-administered, means-tested structure was similar to proposals offered by conservatives previously (such as by Taft in the 1940s), two new provisions imbedded in Kerr–Mills—the concept of medical indigency and comprehensive benefits—put this means-tested program on a more expansionary path and influenced profoundly Medicaid’s subsequent policy evolution (Rosenblatt 1975; Stevens and Stevens 1974; Grogan and Patashnik 2003a and 2003b). Proponents of the Kerr–Mills approach argued that a means-tested program would be more efficient than a universal program because it offered help to the most needy, yet the program was designed to be distinct from “welfare” and thus the stigma associated with it. It was unlike welfare because the “medically indigent” were defined as older people who have large medical expenses relative to their current income and thus only need assistance when they become sick and need medical care—but not otherwise. Proponents emphasized that the “medically indigent should not be equated with the totally indigent;” that is, those who receive cash assistance (Fein 1998). The concept of medical indigency was put in place with the idea that sickness should not cause impoverishment. They also argued that this approach offered the truly needy more security than the Forand bill, which only covered hospital-based services, because it provided comprehensive services including hospital stays, physicians, nursing homes, and drug benefits. In sum, they argued, successfully at the time, Kerr–Mills would provide necessary comprehensive coverage to the truly needy, whereas the Forand bill, offering only hospital services to everyone, would provide inadequate coverage to the truly needy and unnecessary coverage to those not in need.9

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Although it is unclear how much older Americans were helped under Kerr–Mills, the program had a huge impact on the growth and use of public assistance payments to health care facilities. From 1960 to 1965, for example, public payments for nursing homes increased almost tenfold, consuming about a third of total program expenditures (Vladeck 1980). By the end of 1965, all fifty states had programs of medical vendor payments, and forty-seven had specific Kerr–Mills programs for the aged. Taken cumulatively, these incremental expansions—medical vendor payments, the Hill–Burton Act without charity care enforcement, and the Kerr–Mills program— provided important health care services to needy people but also bolstered payments to a separate and unequal health care delivery system for the poor.

MEDICAID’S CURE, 1965 The Social Security Amendments of 1965 (the Medicare and Medicaid legislation) combined three approaches to financing medical care into a single package. The first layer was Medicare Part A, a hospital insurance program based on the Social Security contributory model. The second layer was Medicare Part B, a voluntary supplementary medical insurance program funded through beneficiary premiums and federal general revenues. The third and final layer was the Medicaid program (originally called Part C), which broadened the protections offered to the poor under medical vendor payments and to the medically indigent under Kerr–Mills. The Kerr–Mills means test was liberalized in order to cover additional older citizens, and eligibility among the indigent was broadened to include the blind, permanently disabled, and adults in (largely) single-headed families and their dependent children. Given the focus on Medicare and health care coverage specifically for the elderly, the passage of Medicaid took nearly everyone by surprise (Marmor and Marmor 1970; Stevens and Stevens 1974). Medicaid was modeled after Kerr–Mills and included the same expansionary seeds—medical indigency and comprehensive benefits—as discussed above, but four important federal mandates were also included to strengthen Medicaid’s short- and long-term impact. First, although the medical indigency provision under Kerr–Mills only applied to older people, Medicaid expanded this provision into what became called the Medically Needy Program

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for all recipients. This meant that although medically needy coverage was still optional for states, they could no longer offer coverage to one recipient group (e.g., older people) but not other groups (e.g., needy children and adults on cash assistance). Rosenblatt (1975) points out that in a section titled “Equality of Medical Care” HEW explicitly defined this new rule in its first regulatory material issued for Medicaid (Title XIX): “A basic concept of Title XIX is that of equality of medical and remedial care and services. Its purpose is to erase the differences in the various categories in regard to care and services. What this means in actual operation is that AFDC [Aid to Families with Dependent Children] children will be treated the same as all other recipients” (as quoted in Rosenblatt 1975, 648).10 Second, instead of allowing states to provide comprehensive benefits as under Kerr–Mills, states were now required to offer hospital, physician, and nursing home care as well as laboratory and X-ray services. HEW clearly stated that by 1975 participating states had to provide “comprehensive care and services to substantially all individuals who meet the plan’s eligibility standards” (Rosenblatt 1975, 649). Third, in an effort to interpret legislative intent around the concept of offering the poor access to mainstream medical care, HEW required states (through administrative regulations) to pay physicians and hospitals “usual and customary” fees, which meant that states’ Medicaid fees should be on par with Medicare and private sector fees (Rosenblatt 1975; Stevens and Stevens 1974). Operationally, HEW wanted at least two-thirds of all physicians in each state to participate in the Medicaid program and believed that paying rates comparable to the private sector was imperative to achieve that goal (Watson 1995; Stevens and Stevens 1974). Finally, to induce states to participate in this health care program for the poor with more federal mandates than its predecessors, the federal government increased its financial participation to 75 percent for administrative costs and 50–82 percent (depending on the state’s per capita income) of expenditures for services rendered (Rosenblatt 1975). Taking a close look at Medicaid legislation in 1965—offering the medically needy program and comprehensive benefits for all program recipients combined with important federal mandates about equal Medicaid fees—confirms Rosenblatt’s conclusion that “the ultimate goal (of the program) was the elimination of traditional dual track health care for the poor, and the incorporation of the poor

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into ‘mainstream’ or middle-class patterns of hospital and medical care” (Rosenblatt 1975, 649).11 Indeed, HEW clearly stated this mainstreaming goal in its program material: The Congress has made very clear its intent that the medical and remedial care and services made available to recipients under Title XIX be of high quality and in no way inferior to that enjoyed by the rest of the population. The passage of Title XIX marks the beginning of a new era in medical care for low-income families. The potential of this new title can hardly be overestimated, as its ultimate goal is the assurance of complete, continuous, family-centered medical care of high quality to persons who are unable to pay for it themselves. (Quoted in Rosenblatt 1975, 649–50)12

In light of this ambitious goal backed by an increase in federal financial commitment, it is perhaps not surprising that a number of states adopted the medically needy program and some states set quite generous eligibility levels. New York, for example, enrolled families with incomes up to six thousand dollars per year (for four people) in 1966. As a point of comparison, by July 1991—twenty-five years later—thirteen states with medically needy programs set income eligibility levels below six thousand in current dollars. Under New York’s liberal enrollment standards, almost half of the state’s population in 1966 could have potentially qualified for Medicaid’s comprehensive medical coverage, including access to prescription drugs and long-term care (LTC) facilities (Stevens and Stevens 1974). New York state policymakers envisioned Medicaid as the stepping-stone to universal health care for its residents. As mentioned, this vision emerged primarily out of the “Medically Needy” concept and allowed one to view Medicaid as a health security program to protect all individuals (poor and nonpoor alike) from falling into poverty when they become ill.

MEDICAID’S RETRENCHMENT, 1967, 1969, AND 1972 Despite this expansionary view, a second and much more constrained view of Medicaid existed at the same time. Under this second view policymakers thought of the program primarily as a mere supplement to Medicare. Many legislators perceived Medicaid as a relatively minor piece of the 1965 Social Security legislation, of much less

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significance than Medicare. In President Johnson’s speech on the first anniversary of signing the landmark 1965 legislation, he did not even mention the passage of Medicaid. Government estimates of Medicaid’s future budgetary costs assumed the program would not lead to a dramatic expansion of health care coverage (Stevens and Stevens 1974). Even assuming that all fifty states would implement the new program, the federal government projected Medicaid expenditures to be no more than $238 million per year above what was currently then being spent on medical-welfare programs. As it turned out, this expenditure level was reached after only six states had implemented their Medicaid programs. By 1967, thirty-seven states were implementing Medicaid programs, and spending was rising by 57 percent per annum (CRS 1993, 30). Although policymakers often agreed in principle with the Medicaid goal of equal access and quality care, many thought the program should be contained for a relatively small number of “truly” needy Americans. In their view, the costs could be easily controlled because this number should not be that high. As a result of these conflicting views, the federal government reached an early impasse with Medicaid: Should it embrace an expansive vision of Medicaid or restrict program eligibility to a narrow clientele? Of course, it chose the latter course, clamping down hard on New York’s attempted liberalization. In 1967, only a year after the New York expansion began, Congress passed legislation lowering the medically needy eligibility level to 133 1/3 percent of a state’s AFDC means-tested level.13 New York’s generous six-thousand-dollar eligibility level for a family of four was thereby reduced to thirtynine hundred dollars. As a result of this federal intervention, about 600,000 potentially eligible people were denied medical benefits in 1967. The number of potential Medicaid recipients was reduced by 750,000 in 1968 and 900,000 people in 1969 (Stevens and Stevens 1974; U.S. Congress 1967, 1546). Ironically reminiscent of the conservative Kerr–Mills proponents earlier in the decade, New York state policymakers argued that a liberal definition of the medically needy population was required in order to distinguish the Medicaid program as a whole from welfare. Under the New York program, 70 percent of the state’s Medicaid spending would go to medically needy claimants who did not receive cash assistance. New York state was hardly alone in wishing to distinguish Medicaid from welfare. Eighteen other states also devoted more than half of their Medicaid budgets to those not

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on welfare. In Wisconsin, for example, 74 percent of total Medicaid payments were for medically needy recipients in 1967 (U.S. HEW 1967, table 15). In halting New York’s attempted liberalization in 1967, federal policymakers made a conscious decision to define Medicaid as a restricted welfare program, off limits to the employed. “The House is moving toward a program where you provide medical care to those who can’t pay, and expect people to pay it if they are working and can earn income,” stated one conservative senator in floor debate (U.S. Congress 1967, 1547). Despite this significant retrenchment in 1967, Medicaid expenditures continued to increase, and the federal government responded yet again in two additional statutory amendments in 1969 and 1972. In 1969 the federal mandate to expand medically needy coverage to all groups equally was lifted, and in 1972 the mandate that all states must create Medicaid programs comprehensive in scope and breadth was eliminated. In addition, in 1972 the Supplementary Security Income (SSI) program was created, which consolidated five separate state-run cash assistance programs for the aged, blind, and disabled into a single, federal, means-tested program (Quadagno 1989). Because SSI, unlike most means-tested benefits, is run as a nationally uniform program, a clear bifurcation among Medicaid beneficiaries was established. Older people, the blind, and the disabled—who tended to be viewed sympathetically—gained Medicaid eligibility based on a federal eligibility standard. In contrast, poor mothers and their children gained eligibility according to a (typically much lower) state eligibility standard.14 The creation of SSI made HEW’s earlier statements about equal treatment for all Medicaid recipients ring a bit hollow. Indeed, following the sentiment of the congressional intent, HEW was forced to reverse some of its regulatory language. Most important, it eliminated the Medicaid fee requirement to be on par with Medicare and private fees (Watson 1995). As it became clear that Congress was not willing to support significant Medicaid expansions at the state level, states, especially those under fiscal stress, began lowering their eligibility and benefit levels, as well as fees paid to Medicaid providers. As early as 1974, Stevens and Stevens described Medicaid as perpetuating a two-class system of medical care, in which middle- and upper-income people use private hospitals and physicians, and the poor use a fragmented public system (Stevens and Stevens 1974). Similarly, Rosenblatt concluded that these amendments had “largely diverted Medicaid

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EXPLANATIONS AND BACKGROUND

from its original goal of one-class, quality medicine to its opposite: financing the traditional dual track system” (1975, 651). Yet these amendments had contradictions of their own. Although the 1967 measure tightened considerably the definition of “medically indigent,” it nonetheless maintained the ability of states to distinguish administratively between welfare recipients and those who needed health care but not cash. The 1967 statute also expanded a series of well-child care benefits for poor children, creating the Early and Periodic Screening, Diagnostic Treatment (EPSDT) program. The practical effect was to make the Medicaid benefit package even more comprehensive than it was already (Rosenbaum and Sonosky 1999). Finally, the 1967 law established the so-called freedom-ofchoice requirement, which specified that states could no longer create special clinics for welfare clients or require Medicaid recipients to use county hospitals. Thus, although the equal fee requirement was dropped, this statute reaffirmed the mainstreaming goal by requiring that Medicaid administrators had to allow low-income citizens “to use providers of their choice, to enter the mainstream of American health care”(CRS 1993, 1041, appendix H; see also Watson 1995). Given the consequences of this separate and unequal health care system for the poor, which emerged prior to Medicaid and has persisted for forty years past its enactment, it is not surprising that most analysts describe Medicaid’s early history as pure retrenchment and a rejection of its early, idealized goals. Without disputing the reality of dual-track health care that Medicaid has supported over time, we argue that the key to unraveling public discourse around Medicaid’s goals over time is located in a clear understanding of the contradictions and tensions that emerged from this early period. Although this retrenchment period clearly shows that concerns about controlling Medicaid costs took precedent over the goals of equal access and improved quality, the existence of medical indigency, comprehensive benefits, and the freedom-of-choice requirement assured that the equal access and improved quality goals for the program nonetheless remained. Even when cost control appears to take charge, concerns about equal access and quality remain part of our public discourse because these goals have always been a part of Medicaid policy. Thus advocates for the poor have always at once thrown up their hands at Medicaid’s perpetuation of dual-track health care and yet legitimately hoped that Medicaid could rectify this unfair system.

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EQUAL ACCESS AND IMPROVED QUALITY UNDER COST CONTROL, 1980s The goals of cost control, equal access, and improved quality were at the heart of three main legislative efforts during the 1980s—eligibility expansions for children and pregnant women and their infants, Medicaid expansions for older people, and attempts to increase provider participation.15 Focusing on national-level developments, we illustrate how Medicaid’s goals of equal access and improved quality persisted even under a constrained welfare vision in which the cost control goal remained paramount.

IMPROVED QUALITY WELL-CHILD CARE VISITS AND PRENATAL CARE The federal government enacted incremental Medicaid expansions for children and/or pregnant women and infants in every year between 1984 and 1990. By the end of this six-year period, some five million children and five hundred thousand pregnant women had gained Medicaid eligibility in states across the nation (Rosenbaum 1993). What is most remarkable is that these Medicaid coverage expansions—which helped drive combined state and federal health care spending for the poor from $75 billion in 1986 (measured in 1996 dollars) to almost $180 billion in 1996 (Melnick 1999)—is that they occurred when they did. The federal government faced persistent budget deficits throughout the 1980s. Significant cutbacks in Medicaid spending had been made under Ronald Reagan in 1981 (Tanenbaum 1995). In sum, major targeted Medicaid expansions occurred in an era of general fiscal austerity. Medicaid’s cash welfare recipients certainly did not fare well at the start of the 1980s. The Omnibus Budget Reconciliation Act of 1981 (OBRA-81), which carried out much of Reagan’s budget-cutting agenda, reduced Medicaid spending indirectly by imposing severe cutbacks in AFDC. More than four hundred thousand poor working families lost Medicaid coverage when they were removed from the cash welfare rolls (Cohen and Holahan 1985; Oberg and Polich 1988). In addition, OBRA-81 restricted “categorical eligibility” for Medicaid benefits in various ways, including by eliminating the state option to cover dependent children age nineteen to twenty-one, denying coverage of two-parent families in which only the secondary wage

54

EXPLANATIONS AND BACKGROUND

earner was unemployed, and restricting the duration of Medicaid eligibility for first-time pregnant women. The federal government also lowered the level of its financial contribution to state Medicaid programs, reducing the federal matching rate by 3.0, 4.0, and 4.5 percent over a three-year period (Oberg and Polich 1988). Given the deep unpopularity of the cash welfare system among both the public and policy elites, it is not surprising that Medicaid was damaged by its direct linkage to the AFDC program.16 The Medicaid eligibility restrictions that were enacted in 1981 were actually mild relative to Reagan’s original proposal, which would have transformed Medicaid into a block grant program and terminated Medicaid’s status as a budgetary entitlement. Still, OBRA-81 manifested the basic tensions that are endemic in Medicaid policymaking. Although OBRA-81 sought to narrow Medicaid eligibility by retrenching AFDC, the measure also mandated that states provide Medicaid coverage to adults who were removed from the welfare rolls for a nine-month transitional period. The aim was to ease welfare recipients’ entry into the paid work force. The federal government even offered to share the costs with any state that wished to extend this transition period for an additional six months. Many states eventually opted for the extra six-month option. This littlenoticed feature of OBRA-81 illustrates yet again—in this instance simultaneously within the same bill—the multiple and indeed conflicting ways that Medicaid is portrayed: (1) as assistance for the “totally indigent” (i.e., welfare dependents), (2) as a program to transition welfare dependents into work, and (3) as policy carrot for working families to discourage welfare dependency in the first place. All told, the targeted Medicaid expansions adopted from 1984 to 1990 increased the number of people receiving Medicaid benefits to thirty-six million in 1996, up from an average of twenty to twentythree million between 1973 and 1989 (Melnick 1999, 31). Most of the Medicaid expansions for pregnant women and children began modestly. They were initially designed as options presented to the respective states for their consideration, with the federal government making available matching funds. Only later were these expansions gradually converted into federal mandates. For example, coverage of pregnant women and infants up to 100 percent of poverty was a state option in 1986 but became a federal mandate in 1988. Similarly, the Medicare “buy-in” (described below) was optional in 1986 and required in 1988 (Grogan 1999).

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Many states responded favorably to the optional expansions. Participating states were, in general, not required to make any changes in their basic Medicaid eligibility definitions when the mandates were imposed. For example, when the 1988 mandate was passed to expand coverage to 100 percent of the poverty level for pregnant women and infants, 76 percent of the states were already compliant. When this mandate was expanded again the following year to 133 percent of poverty, 40 percent of states were still compliant. An obvious appeal of these Medicaid expansions was that they targeted pregnant women and their children—groups widely seen as morally deserving. Yet expansion proponents did not base the case on normative claims alone. Rather, they argued that extending Medicaid coverage to these groups was desirable because it was cost-effective. Although infant mortality had decreased over time, low birth weight remained a stubborn problem in the 1980s, especially for the babies of poor mothers from minority backgrounds. Health care costs associated with low-birth-weight babies were skyrocketing due to both technological improvements that allowed babies of lower and lower birth weight to be saved and to an exogenous increase (attributable to several factors) in the rate of low-birth-weight babies. Infants with a low birth weight were not only expensive to insure postdelivery, but they faced a significant risk of serious medical problems throughout their lives. Proponents argued that minimizing these problems through inexpensive prenatal care made good economic sense. A similar pragmatic argument was made for increasing coverage for children: inexpensive immunizations and well-child care were portrayed as good investments for a healthy population and strong future workforce (Sardell 1988, 1991; Tanenbaum 1995). As long as the goal of quality improvement was couched as costeffective, it could be viewed as complementary with the goal of cost control.

EQUAL TREATMENT WITH EXPANSIONS FOR OLDER AMERICANS Because Medicare does not cover most of the costs of long-term custodial nursing home care, and relatively few Americans have been able or willing to purchase private LTC insurance during their working years, citizens often arrive in old age unprepared to cover the expense of custodial nursing home care. As a result, when older

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people need such care the vast majority fall back on Medicaid. As early as 1975 Medicaid was paying the bills of more than half of all nursing home residents. Many seniors in nursing homes are not eligible for Medicaid at the time of their admission. At an average cost of thirty thousand dollars per year, however, nursing home care quickly depletes the resources of all but the most affluent seniors. Between 27 and 45 percent of older nursing home residents become eligible for Medicaid after spending down their resources. A significant proportion of older nursing home residents on Medicaid are not poor by typical “welfare” standards (CRS 1993). Indeed, some spent their adult lives firmly in the middle class. States cover these “nonpoor” people under either their Medically Needy programs or under a special income rule called the “300 percent rule.”17 Together, these two sets of programs account for 88 percent of Medicaid’s nursing home spending and 75 percent of total Medicaid spending on older people. By the late 1980s Medicaid was serving as the public support of last resort for many older Americans in nursing homes. Policymakers recognized, however, that many senior citizens remained anxious about their rapidly rising out-of-pocket medical costs and about the continuing lack of guaranteed protections in numerous areas (from acute hospital stays to long-term care). For those with serious conditions, out-of-pocket costs could reach catastrophic proportions. Low-income older people not receiving Medicaid spent on average 25 percent of their income on medical bills (Rosenbaum 1993). In response to these concerns, Congress in 1988 mandated that states use their Medicaid revenues to pay for the Medicare premiums of eligible seniors. And in the ill-fated Medicare Catastrophic Coverage Act of that year, Congress raised the amount of money seniors in the community can keep when their spouses receive Medicaid benefits as residents of nursing homes. This new protection against spousal impoverishment—along with the “Medicare buyin” requirement that states pay the Medicare premiums, deductibles, and copayments of seniors with incomes below the poverty level—solidified Medicaid’s de facto role as the United States major LTC program. Yet allowing Medicaid to remain the main source of governmental aid for nursing home residents created its own set of political tensions. By the late 1980s, Medicaid’s prominent role in supporting nursing home care led to renewed concerns about unequal treatment among program recipients. Although older people comprise less

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than 15 percent of Medicaid recipients, they account for more than 30 percent of the program’s costs, in large part because of their nursing home care (Rosenbaum 1993). Although concern about generational equity in the American welfare state has focused mainly on Social Security and Medicare, some advocates for poor children argued that it was inappropriate for a disproportionate share of Medicaid dollars to go toward supporting older people while younger people were struggling to pay for their health care (Benjamin, Newacheck, and Wolfe 1991). With federal mandates in the 1980s that expanded benefits to both “cost-effective” pregnant women and children and then expansions to “expensive” older people, representatives from the states started to voice concerns that they could not legitimately finance expansions to both groups, that difficult choices needed to be made or expanding long-term care costs would result in fewer services for poor families. A representative from the state Medicaid Directors’ Association put the issue starkly: Obviously, for the private payer, the spousal protections . . . are very desirable and very needed. As you reduce their share of the cost, you are again passing those increases onto the Medicaid program. I’m not suggesting that you not do it, only to keep in mind that those Medicaid budgets are being consumed by long-term care expenditures. Because state revenues and local revenues are not limitless, again choices have to be made. What we are seeing in effect is Medicaid by default becoming a long-term care budget and not being able to cover more of the primary health care needs of women, children and families. (U.S. Congress 1988, 100-74, Matula testimony, May 28, 1987, p. 433)

Thus HEW’s original goal for equal treatment across all Medicaid recipients continued to surface throughout Medicaid’s history and became paramount by the early 1990s after LTC expansions for older people were passed.

EQUAL ACCESS PHYSICIAN PARTICIPATION AND FQHCS In the early 1970s, when HEW lifted its regulation around reasonable rates on par with private and Medicare rates, states lowered their Medicaid fees and physician participation in the program did decline. Despite the lack of data about this early period, several studies associate this early dramatic decline in physician Medicaid participation

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EXPLANATIONS AND BACKGROUND

to the decline in Medicaid fees (Spiegel and Podair 1975).18 Several reports from specific cities also emerged during the early 1970s deriding Medicaid for its support of substandard care (Rosenblatt 1975).19 A report on Medicaid in Chicago called it “slum medicine” (DeVise and IRSC 1969). Several Medicaid advisory boards at the federal level and in the states issued reports stating the serious problems that lack of physician participation was bringing to the program (Kentucky Advisory Council for Medical Assistance 1980; Myers 1975). The consistent conclusion from these reports and studies was that Medicaid fees should be increased so that more providers would be willing to see Medicaid patients, but in the meantime (and because providers have no obligation to treat the poor) community health centers (CHCs) in underserved areas should be built to provide more primary care services, which were severely lacking. Twenty years later, many CHCs were built, but Medicaid fees remained substantially below private rates paid for the same services. Not surprisingly, participation data continued to show a bleak picture of access to private office-based physician services for Medicaid recipients. Indeed, the problem had actually worsened over time. Although the percentage of physicians accepting any Medicaid patients had remained about the same in the mid-1980s compared to the 1970s, as time progressed more physicians were limiting the number of Medicaid patients they were willing to accept. In other words, in the 1980s, Medicaid patients actually comprised a smaller proportion of physician caseloads compared to the 1970s (CRS 1993). Such findings again raised serious concerns that due to a lack of physician participation in the program, Medicaid enrollees were largely being forced into public institutions to access medical care. In short, the two themes—no provider obligation to take care of the poor and a resulting accepted used of public facilities—continued to characterize health care for the poor in the U.S. Needless to say, the Medicaid program was far from achieving its mainstreaming goal. In 1989, Congress responded to this concern about the lack of physician participation in the Medicaid program in the same way it always had: by (1) amending the Medicaid Act with the intent of inducing states to increase their Medicaid fees and (2) expanding the community health center model and creating Federally Qualified Health Centers (FQHCs). FQHCs included the existing federally funded community and migrant health centers (FFHC), health care programs for the homeless funded under the Stewart McKinney

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Homelessness Assistance Act, as well as outpatient health programs operated by Indian tribes (Rosenbaum 1993). The main goal of FQHCs was to provide high-quality comprehensive health care in underserved areas. “High-quality” health care was specifically defined as care that tended to unique needs of people living in impoverished neighborhoods. For example, because good follow-up care is often a problem for the poor, FQHCs try to serve as places where onestop health care “shopping” can occur; thus, ideally, mental health and more common specialty services are provided on site. Moreover, because many studies identify barriers to accessing health care beyond financial considerations, FQHCs provide enabling services to address these problems, including translation services, transportation, and child care (ibid.). Some studies show that FQHCs actually provide higher quality care to the poor than that which can be provided in a typical private physician’s office because they are set up to accommodate the specific needs of the poor (Falik, Wells, and Korb 2001; Frick and Regan 2001). However, other studies suggest that the care provided by FQHCs, like other public health care facilities before them, suffers from the same old problems endemic to serving a large poor population with enormous needs: overcrowding and long waiting lists, lack of specialty care, and lack of adequate physician-patient communication. Nonetheless, even with high-quality FQHCs, many still hoped (as the passage of both pieces of legislation suggests) that an increase in Medicaid fees would increase physician participation and the choice of mainstream access (along with FQHCs) would finally be realized for Medicaid patients. There was remarkable agreement prior to 1989 that Medicaid reimbursement was the most salient factor influencing physician participation in the program (Sloan, Mitchell, and Cromwell 1978; Hadley 1979; Davidson 1982; Mitchell and Schurman 1984; Gabel and Rice 1985; Perloff, Kletke, and Neckerman 1986).20 This federal rule did appear to have an impact. States increased their Medicaid physician fees by an average of 15 percent between 1990 and 1993 (Watson 1995).21 Unfortunately, these fee increases had little to no impact on Medicaid physician participation rates. After analyzing data from 1990 to 1993, Perloff, Kletke and Fossett (1995) expressed skepticism about the extent to which increasing reimbursement rates can really change physician participation levels. Although Medicaid reimbursement was a statistically

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significant factor in influencing physician participation, they found the marginal effect of fees to be small: If Medicaid payments were increased to the Medicare level—a difference of $7.38—the proportion of primary care physicians participating fully would increase by only about 7.5 percentage points, from 36.4 to 43.9 percent. Similarly, a Medicaid fee increase of roughly $13 (an increase of nearly 60 percent) would be required to reach the OBRA-89 target of 50 percent of physicians participating fully. . . . In large metropolitan areas, the fee increase needed to reach 50 percent full participation among primary care physicians would be even larger. A fee increase of about $18 would be required to reach this target, bring the Medicaid fee to nearly $39 (an increase of 85 percent), $11 (about 39 percent) above Medicare fees. (22)

In light of states’ fiscal stress at that time, and the unlikelihood that states would increase fees to the extent described above, Perloff, Kletke, and Fossett concluded that raising Medicaid fees to improve access to private, office-based physician care would not be a successful strategy.22 The conclusion from another study of a 30 percent fee increase in New York state concurred with Perloff, Kletke, and Fosset’s findings, noting that “a marginal increase in New York State’s low Medicaid fees will not have a positive effect on physician participation levels” (Fanning and de Alteris 1993, 27).23 In most states, a handful of public clinics take care of the vast majority of Medicaid recipients (Brodt, Possley, and Jones 1993). Although Adams’s (1995) study of a fee increase in Tennessee found higher fees lead to increased physician participation, she also discovered a negative association between residential segregation and participation.24 Consistent with a report by the Physician Payment Review Commission in 1992, and studies by Fossett, Peterson, and Ring (1989), Adams suggests that if residential segregation has an important impact on participation, then “policies should focus on expanded support to inner-city hospitals, community health centers, and local public clinics” (Adams 1995, 85).25 It is important to note that in the name of improving access to care, this strategy relies on—and indeed would enhance— our dual-track system of health care.26 Finally, three separate studies based on physician surveys found physician attitudes about Medicaid recipients and the Medicaid

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program to be as important as Medicaid fees in influencing physician willingness to participate (Nesbitt et al. 1991; Margolis et al. 1992; Komaromy, Lurie, and Bindman 1995).27 In summary, by the early 1990s there was a general sense of despair that Medicaid could ever achieve its mainstreaming goal. There was a real questioning as to whether fee increases alone could substantially increase physician participation in the program. And there were legitimate suggestions put forth that policymakers should abandon the mainstreaming goal for the Medicaid program altogether. For example, in a commentary on the state of the Medicaid program, Stephen Davidson noted that “for both political and economic reasons, Medicaid can never be what its original planners had hoped, the vehicle for providing the poor with reliable access to mainstream medical care” (Davidson 1993, 43).

HOPE IN MEDICAID MANAGED CARE, 1990S In the early 1990s policymakers readily characterized state Medicaid programs as administrative failures. To be sure, most policymakers acknowledged that Medicaid played a crucial role in providing health coverage for millions of Americans. Yet there was broad agreement—among Republican and Democratic officials alike— that Medicaid suffered from serious operational flaws. Medicaid still failed to cover many needy people, and the health care it offered was too often of low quality and provided inefficiently. Numerous studies documented that Medicaid recipients were much less likely than Americans with private health insurance to have a relationship with a primary care doctor or to receive needed preventive care and much more likely to receive their care in hospital emergency room settings or public clinics with long waiting lines (Davidson and Somers 1998; Brodt, Possley, and Jones 1993; CRS 1993). Despite the targeted efforts to increase prenatal care and well-child care coverage in the 1980s, a large proportion of Medicaid women still received no, or only minimal, prenatal care services (Colburn 1991). Many children enrolled in Medicaid were failing to receive needed immunizations (Slovut 1991). Layered atop these concerns about health care access and quality were concerns about Medicaid costs. Although the annual growth rate of Medicaid spending declined immediately following the retrenchment period in the early 1980s, Medicaid costs rose steadily thereafter. As the program

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expansions for children and pregnant women and other legislative changes for older people and the disabled adopted in the 1980s and early 1990s were phased in along with fee increases, Medicaid expenditures shot up (Coughlin, Ku, and Holahan 1994, 48–51; Rowland et al. 1993). Yet if Medicaid spending was growing rapidly in the 1990s, so too were the ranks of the uninsured.28 Many policymakers argued that it was inequitable to provide Medicaid coverage to the nonworking poor at a time when two-thirds of uninsured Americans came from families with at least one working parent (Beamer 1999). When Medicaid was originally created, the assumption was that aid should be offered to those who could not afford health insurance because of their lack of employment (U.S. Senate 1967, 1547). By the 1990s, however, it was widely acknowledged that being employed does not guarantee affordable health insurance coverage (Blendon, Young and DesRoches 1999). The inability of the working poor to obtain affordable health insurance further promoted the view that Medicaid should be a program distinct from welfare. States were encouraged by incentives offered through federal Medicaid waivers to “solve” these problems by implementing Medicaid managed care. In 1993, President Clinton ordered the federal government to make it easier for states to use Medicaid funds to introduce new health care programs for low-income families. The federal Health Care Financing Administration streamlined its waiver application process so that more states could implement Medicaid managed care reforms (Friedman 1993). National policymakers promoted the managed care approach almost as a “magic bullet” solution: It promised simultaneously to reduce costs, improve access, raise the quality of delivered services, and even expand coverage to the uninsured (Grogan 1997; Hurley and Somers 2003; Schlesinger, Gray, and Gusmano 2004). Given the intense pressures they faced to improve Medicaid services, rein in program costs, and expand access to the uninsured, state Medicaid policymakers were eager to experiment with this new administrative approach. By January 1995 forty-nine states (all but Alaska) had implemented a Medicaid managed care program. Nationally, total enrollment in Medicaid managed care nearly doubled in 1994 and increased 51 percent again in 1995 (Horvath and Kaye 1995; Grogan 1997). States under Democratic legislative control were just as eager to implement managed care reforms as were

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states under Republican legislative control. Ideological and other political factors were swamped by the appeal of reduced costs, increased access, and improved quality of care. Under Medicaid managed care, states contract with HMOs at 95 percent of the current cost to run their Medicaid programs. Each state pays HMOs a preset monthly amount for each member in the plan whether or not the member actually utilizes any medical care services during the month. The theory is that HMOs make money by emphasizing preventive care and reducing unnecessary utilization of expensive medical services, such as preventable emergency room use. Efficient HMOs, for example, may be able to provide services at only 85 percent of the cost baseline, allowing them to retain the 10 percent difference.29 There is also hope that Medicaid managed care would achieve mainstream access (Iglehart 1995). In particular, by contracting with HMOs, policymakers hope that HMOs will use their market-based leverage (and other strategies such as increasing fees) to convince commercial providers to participate in the Medicaid program (Holahan, Weiner, and Liska 1997). Findings from Holahan et al.’s (1998) analysis of Medicaid managed care programs in thirteen states illustrate this point: “They (policymakers) doubt that higher rates will increase the number of Medicaid providers. The state officials with whom we spoke see a greater likelihood of improved access if managed care plans are required to attract and retain an adequate number of providers” (44–45). Similarly, Oliver (1998) concludes from his study of Medicaid managed care in Maryland that many reformers view the use of managed care contracting as an opportunity to open up access to mainstream providers and services. Medicaid advocates also frequently appear to support Medicaid managed care specifically because they view such reforms as an opportunity to overcome the stigma associated with the traditional Medicaid program. For example, the director of a Phoenix-based philanthropy touts Arizona’s Medicaid managed care program because “many Medicaid patients have access to mainstream private physicians whom they did not previously have access to. They don’t feel like charity patients anymore” (Iglehart 1995). And consumer advocate Geraldine Dalleck, from the Families USA Foundation, writes, “Medicaid managed care may offer the last, best opportunity to provide integrated health care for the nation’s poor” (Dallek 1996).

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CONNECTICUT’S HOPE IN MMC, 1993–1995 A number of factors contributed to Connecticut’s interest in Medicaid managed care. Perhaps most significant were the state’s fiscal crisis in the early 1990s and the rapid growth of its Medicaid program between 1985 and 1994. Like many other states, particularly California and those in the Northeast, Connecticut continued to feel the effects of the 1990–1991 national recession for a few years after it ended in March 1991 (Gold, Sparer, and Chu 1996). And as in many of these other states, Connecticut’s economic slowdown and state budget crisis were exacerbated by the growth of the state’s Medicaid program. Between 1985 and 1994 total state Medicaid expenditures jumped from $5 million to roughly $1.6 billion (Connecticut General Assembly 1996, 21). The number of people eligible for Medicaid increased by 31 percent between 1991 and 1994. In contrast to the general fund budget, which increased by 20 percent, the state’s Medicaid budget increased by 35 percent between 1991 and 1994 (Connecticut General Assembly 1996, 22). Because the Medicaid program represented roughly one-quarter of Connecticut’s General Fund, the growth in Medicaid costs had a dramatic effect on the budget. This generated a considerable amount of interest in containing Medicaid costs. However, Connecticut’s Medicaid officials were also interested in expanding access to care for the program’s recipients, and they thought that managed care would help them achieve this goal. Similar to the longstanding goals throughout Medicaid’s history, they were concerned that recipients were not receiving needed services of sufficient quality. In 1994 less than half (48%) of all practicing physicians in Connecticut participated in the Medicaid program, and even among participating physicians, the majority of Medicaid patients were cared for by a relatively small percentage of Medicaid providers: 20 percent of physicians participating in Medicaid in 1994 provided care to about 80 percent of Medicaid patients (Grogan, Merrell, and Schlesinger 2002). On the issue of access to mainstream providers, not much had changed in Connecticut (or elsewhere in the United States) since the early 1970s: The vast majority of poor families on Medicaid received their care in publicly funded clinics or hospital primary care centers. During our interviews, officials articulated two reasons they believed that private HMOs could do a better job of expanding access to services for the Medicaid population. First, they thought that

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HMOs would have more resources for outreach. State Medicaid officials claimed that under the fee-for-service program, the governor and general assembly had been unwilling to appropriate enough funds to the department for effective outreach to the Medicaid population. Second, Connecticut Medicaid officials believed that HMOs would be more effective in encouraging physicians to participate in the Medicaid program. For years state officials had been frustrated by the low participation rates of physicians, particularly pediatricians and obstetricians. Connecticut was another state that experimented with Medicaid fee increases but found no differences in participation rates. DSS found, in 1993, that fifteen hospital-based outpatient clinics in Connecticut still accounted for 72 percent of all Medicaid patient visits in the state. Although a rigorous quantitative study of the impact of Connecticut’s fee increase was not conducted, policymakers in the state concluded from their experience that increasing fees was not an effective policy tool. In particular, they commented that increasing fees did not improve access for Medicaid enrollees and only resulted in giving currently participating providers more money.30 They believed that HMOs were in a better position to expand physician participation because they would have more leverage over providers. HMOs could, in theory, make participation in their private insurance networks contingent upon the willingness of physicians to accept the plan’s Medicaid patients. After the establishment of the MMC Council, DSS was invited to present the administration’s goals for the program. According to DSS, the initiative was designed to improve health, expand access to care, promote continuity of care, and reduce long-term Medicaid costs. DSS placed great emphasis on the capacity of managed care to promote growth of delivery networks. Among the criteria DSS claimed it would use to evaluate managed care plans were their ability to include historical Medicaid providers and their ability to bring “new points of access to Medicaid eligibles” (DSS PowerPoint presentation, Legislative Office Building, Hartford, Conn., August 23, 1994; emphasis added).

CONCLUSION The goals of Connecticut’s MMC reform—to control costs, improve quality, and expand access to mainstream medical care for

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Medicaid recipients—were neither new nor unique to the state. As our review of Medicaid’s forty-year history suggests, providing highquality, mainstream medical care at reasonable costs have been the primary aspirations of the program since its inception. Indeed, the persistence of these goals is remarkable in light of our limited success in achieving them. When Connecticut adopted MMC, its proponents argued that this new contracting regime would allow the state to finally realize these longstanding goals. Because DSS and the newly formed MMCC emphasized the goal of mainstreaming during its initial meetings, coupled with the fact that mainstreaming was an important goal in several states that adopted Medicaid managed care, we expected this issue to be prominent in public deliberations about the Medicaid reform, alongside the goals of improved quality and cost control. As we discuss in the remaining chapters, however, the issue of mainstreaming fell off the agenda for public discussion rather quickly and never fully reemerged.

PART II Arguments and Findings

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4 The Political and Policy Difficulties of Discussing Unequal Access

Starting in August 1995, AFDC-Medicaid recipients living in Connecticut’s two largest counties were given the option to enroll in a Medicaid managed care plan.1 Recipients’ response to the new program was extraordinary: By the end of the month, nearly ten thousand Medicaid recipients had enrolled in eleven different Medicaid HMOs. The number of voluntary enrollments was far greater than anyone—even the agency responsible for administering the program (the Department of Social Services), Medicaid advocates, or the HMOs—had anticipated. Not surprisingly, especially given this level of unanticipated demand, a number of enrollment difficulties arose during the first few months of the program. Medicaid Managed Care Council members, many of whom worked on some aspect of the program, shared anecdotes about the poor quality of information available to Medicaid recipients and worried about the extent to which recipients were making informed choices. Early in the implementation stage, in a January 1996 meeting, many council members raised concerns that Medicaid recipients were making uninformed choices. Medicaid advocates were specifically worried that Medicaid recipients were choosing commercial plans under the belief they were getting a commercial product (i.e., access to more “mainstream” private providers), when in fact they were getting a separate Medicaid-HMO plan. For example, Blue Cross Blue Shield (BCBS) of Connecticut created a Medicaid plan called Bluecare that had a list of providers different from the list of providers private paying subscribers received. The commercial insurers’ Medicaid plans had many “traditional” Medicaid providers (primarily those practicing in public clinics) as well as “new” private physicians on their Medicaid

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panels, but the extent to which private providers actually participated was unknown. Although there were many new private physicians listed as participating in MMC, there was no information on the extent of provider participation in the program. For example, a physician could be listed as available on an HMO’s brochure but only see one or two Medicaid patients in any given year. Moreover, there was some concern about the validity of the HMO lists because there were reports of physicians on the lists who had no idea they were listed and had no intention of seeing a Medicaid patient. This happened because some HMOs had very lenient physician participation rules (Grogan and Schlesinger 1999). For example, one HMO simply sent all its private physicians a letter stating that the plan would add the physician to its Medicaid list of participating providers unless the plan heard back from the physician stating that she or he did not want to be listed (ibid.). This represented a type of “regrets only” participation rule. This approach, combined with the lack of data about how and whether physicians were actually participating in MMC, created two divergent views about the access goal. Some looked at the lists and said that MMC created access to mainstream providers, but others doubted the accuracy of the lists and thought HMOs were simply creating a mirage. In the January meeting several explicit concerns about equitable treatment were raised. For example, one state senator said he was aware of differences between the commercial networks and Medicaid networks, thought it unfair to Medicaid recipients, and “believed the plans should do a better job encouraging commercial providers to join the Medicaid networks” (#75).2 Another state legislator noted that “many who have voluntarily chosen a plan think they selected the BCBS commercial plan, but they have not. When they do find out there is a big difference, they are having problems” (#16). Representatives of the poor provided their own anecdotes suggesting the state was unfairly misleading recipients into thinking they were getting more from HMOs than they were actually given. For example, a Medicaid advocate said she had visited housing projects and talked with clients “who have chosen BCBS, but did not understand what they were getting (#71).” Although many members were concerned about equitable treatment, given the existence of separate Medicaid networks, the conversation abruptly ended when a representative from BCBS said “there are more providers in our Medicaid network (under this new managed care reform) than had served the population under

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Medicaid’s previous FFS program” (#54). Once the incremental claim—that this reform program is an improvement over the previous approach—was brought to the fore, discussion about how well the program was achieving this goal ended. Indeed, this particular issue was never raised again during the remaining sixteen months of the public meetings we observed. Why?

PRIVATE ASSESSMENTS OF MAINSTREAM ACCESS Perhaps the MMCC did not discuss the mainstreaming goal because the majority did not believe it was important. Or perhaps felt it was simply not as important as the other goals of MMC. To our surprise, however, without even asking specifically about the mainstreaming goal in our private interviews, the majority of participants mentioned it as the most important challenge of MMC. In response to a very broad question about the most difficult challenges facing the Medicaid program, 62 percent of participants mentioned access to providers (or the lack of provider participation) in the program as their most pressing concern: “Quite frankly, I thought that the access to services would be better under a private managed care system than under the Medicaid system, which had such difficulty getting physicians, pediatricians in particular and obstetricians, to sign up. . . . And I thought that this private managed care program could do a better job of it” (#100, state bureaucrat). One in four (27%) specifically emphasized the lack of access to mainstream providers and the challenge of eliminating dual-track medicine. As one participant put it: “I think the single most important challenge for MMC is how to prevent the creation of a dual system of care, and it’s ironic that that would be the issue since managed care was all about eliminating the public sector/private sector distinction and putting everybody in a pool” (#53, health plan representative). Although the majority of participants mentioned “lack of provider participation” in our private interviews as an important challenge facing the MMC program, another possible explanation for the lack of public discussion might be that the vast majority of participants agreed with the representative from BCBS that provider participation under MMC was sufficient and access to the mainstream providers had improved. However, when we specifically asked participants in the private interview whether MMC improved recipients’ access to mainstream providers, there was a great deal of disagreement.

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About half (47%) of the participants disagreed with the statement that Medicaid managed care improves recipients’ access to mainstream providers and services. Their comments tended to focus on the fact that plans created separate Medicaid provider networks, which were different from their commercial networks, and/or that private providers still refused to participate in Medicaid managed care: It’s a bifurcated plan. . . . What I feel would be equitable is if our hotshot neurologist, or my hot shot dentist, were mandated to have a percentage of his patients be Medicaid recipients. That’s what I think is equitable. . . . I don’t think, from what I have been hearing, that is happening. (#62, provider representative) Providers sign up and they’re part of the plan, but they don’t really take Medicaid clients or they only take one or two. . . . Or they set it up so that all Medicaid come in on Wednesday. That’s not exactly mainstream. (#92, state bureaucrat)

In stark contrast to these comments, the remainder of participants (52%) expressed confidence that recipients now have access to mainstream providers. Their view, as illustrated below, is based primarily on the fact that many commercial providers have signed up with various health plans to provide services to Medicaid members. Their responses tended to focus on the overlap between commercial and Medicaid networks where providers serve both populations or—similar to the BCBS respondent mentioned above—they focus on the word “improve” (that recipient access to mainstream providers and services has improved): Because with the managed care plans, you’re talking about health plans that serve both the Medicaid and the commercial populations, so it’s the same doctors, whether they’re on Medicaid or not. They have access to everyone just like everybody else does—the same doctor seeing the same Medicaid patient and an IBM employee. (#51, health plan representative) I think [MMC] has improved it. I think we’ve seen already that the eleven plans certainly have allowed more providers in the network. Still not enough, certainly in a lot of areas, but the word we hear is that there’s more than there ever were in fee-for-service. (#38, health plan representative)

Similarly, participants had very different assessments of whether Medicaid managed care is reducing the welfare stigma associated with the program. Because mainstreaming, in theory, is supposed

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to reduce stigma, this question about mainstream access led many respondents to discuss (unprompted) the issue of stigmatization. Among those who raised the issue (seventeen people), half believe the two-tiered system remains, whereas the remainder believe Medicaid patients are no longer labeled. The following quotations exemplify these opposing perspectives: When I looked at the network, Blue Care and a couple of the other larger, well-known names, . . . the HMOs actually only have apartheid care. They have a set of providers for the mainstream population and a different set of providers for the Medicaid population that was in the same health plan. So they created like a special division. Two layers. (#19, advocate) I think that was one of the major concerns of some of the AFDC recipients, is that they would be treated in the same way as the general population. If we’re signing on with HMO X, are we going to be stamped on the arm with a AFDC symbol and will we be treated differently from the rest of the population? The majority of the HMOs have assured them that will not be the case. And thus far, with some of the survey information that we’ve seen, that indeed is the case— they feel that they have been receiving good care. (#7, advocate)

Thus emerged our puzzle: If the majority of participants mentioned access to mainstream providers as one of the most important challenges, and there was stark disagreement as to how well the program was fulfilling this goal, why did participants raise the issue so infrequently and why wasn’t the conversation about the topic sustained when it was raised?

ABLE REPRESENTATIVES FOR COST AND QUALITY GOALS Political inequality is logically a common explanation for instances of political suppression. In our case, one might argue that participants who cared about equal access chose not to discuss the topic in public because they lacked political power and feared some type of rebuke. We consider this argument below. It is important to remember from our interview data presented above that it was not just a small minority of participants who cared about mainstream access: 62 percent mentioned it as an important topic and challenge for MMC without being prompted or asked about the topic. And there was not a consensus about the topic; that is,

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participants disagreed about how well MMC was doing on expanding access to private physicians. Thus, on the one hand, given this level of interest and disagreement, the topic seemed ripe for public discussion. On the other hand, it was only in the interest of Medicaid advocates to raise the issue in the public forum. Although many participants mentioned the concern in our private interviews, it was not in the interest of either HMO or DSS representatives to raise the issue in the public forum because it questioned the performance of HMOs to attract private physicians to the Medicaid program and in this sense criticized the Department of Social Services’s administration of MMC. In contrast, advocates were specifically invited to participate in the public forums to represent Medicaid clients. They were concerned about this issue and it was in their interest to raise it in the public discussion and yet they were silent. In keeping with the political inequality argument, one might presume they kept silent because they either lacked political power or because they lacked policy expertise and therefore deferred to experts. Yet neither of these presumptions holds up under closer scrutiny. First, as we will describe in more detail in the next chapter, Medicaid advocates won several major legislative victories around MMC reform. By advocates’ own account they had significant influence over the design of MMC. Second, if we analyze the topics advocates chose to discuss in the public forum, we find that they were not afraid to confront conflict, and they did not defer to experts. We describe this public discourse around the cost and quality goals below to illustrate how advocates were clearly able representatives who did not avoid conflict or defer to experts. Starting with the first meeting we observed, program costs were discussed repeatedly. Despite the frequency of the topic, these discussions were never simple or straightforward. To the contrary, participants often commented about the complexity of the rate setting methodology and difficulty in understanding it. Despite the complexity, however, participants were unrelenting; they continued to press on the meaning of the numbers. For example, after a DSS consultant gave a technical presentation on the methodology behind the department’s decision to lower the capitation rate from $155 to $142 for the HMOs, state senator Edith Prague was about to ask a detailed question and then said, “Oh never mind, I think the numbers will just blow my mind here.” And yet she persisted with an effective, simple question: “Does each plan get $142 per member

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per month?” The consultant replied, “There are forty-eight separate rates for each plan. The debate about the $142 is about what the real average should be” (February 2, 1996). Despite this rather vague response, other members of the MMCC— including advocates for the poor—pressed forward. They asked extensive questions about the rates for newborns, the stop loss coverage DSS was providing with the lower rates, and how the cost of new eligible groups—foster care children and pregnant women— would be factored into the rate. After this discussion, the provider representative for the council spoke: Provider rep: I’m not confident that rate is right. DSS consultant: I feel very confident that this rate is right. Provider rep: We are going to expand access based on this rate, and I’m not convinced the plans don’t have something to be concerned about.

Two Medicaid advocates then joined in: Medicaid advocate 1: Someone suggested rates would go up, not down. HMOs were counting on an increase in the rates. Help me understand why these differences exist. Help the layperson understand. DSS consultant: It is very complicated, there are so many factors. . . . Medicaid advocate 1: Okay, I know, it’s very complicated, and that it is beyond me, but help at the policy level. [For example,] how is Fairfield county $123 and Tolland county $179? What does this tell us? DSS consultant: We can quantify the numbers and show that these numbers are persisting year after year. You should not infer poorer access where the rates are lower. A lot of research still cannot answer why such variations occur. Medicaid advocate 2: But, this does reflect differences in access. Do we want to pay based on regional variations that currently exist? Do we want to perpetuate those variations?

This public exchange reveals that advocates were not afraid to challenge technical experts even when they acknowledged a lack of full understanding about the topic. The differences in the rates between counties just did not make intuitive sense to most people

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on the council or to those participating in the subcommittees. Many participants asked, “Why is it that Fairfield County has the highest cost of living and yet is given the lowest capitation rate?” Therefore, despite a detailed explanation from technical experts many participants remained skeptical and pressed to figure out what they disagreed with in the technical methodology. Advocates seemed to appreciate the importance of policy details embedded in the data and often used the public forum as an opportunity to better understand certain aspects of the program. But they were not just passive learners. After receiving information, they would often shift into a more conflictual mode to make their point. Similarly, participants actively engaged in extensive discussions about how to measure the quality of care provided by HMOs. Determining how to measure quality—actually defining the parameters to use—is a particularly difficult process (Hibbard, Stockard, and Tusler 2003; Adams and Corrigan 2003; Iezonni 1997). It took hours of subcommittee work, and there was no guarantee that DSS would use them. At every MMCC meeting someone from the subcommittees raised the issue and asked what DSS was doing to measure quality of care and access to services. Although the federal government requires states to hire an external organization to monitor access and quality, DSS was still lacking a signed contract a year after implementation began. Not surprisingly, council members were upset about the lack of progress, and every month they would ask DSS about their efforts to develop baseline data and plans to monitor the program. When, in January 1997, DSS hired a local organization to monitor the program, many council members, including advocates, expressed great concern that they be involved in the process of designing a Quality Assurance (QA) program. As a result of advocates’ persistent efforts—raising the issue at every MMCC meeting, extensive work on designing quality parameters in the subcommittee meetings, working with “quality experts” to understand measurement issues—DSS agreed to meet with the subcommittee and incorporated some of their recommendations in the quality monitoring design. Thus we are back to our central puzzle. If the majority of participants mentioned the lack of access to mainstream providers as one of the most important challenges, and there was stark disagreement as to how well the program was fulfilling this goal, and advocates— those with the greatest interest in raising this concern—were not afraid to confront conflict or challenge technical experts, why did

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advocates raise the issue so infrequently, and why wasn’t the conversation about the topic sustained when it was raised?

IMPACT OF INSTITUTIONAL FACTORS ON PUBLIC TALK An alternative explanation for the silence problem, which draws from Kingdon’s model of agenda setting, suggests that institutional factors—political feasibility, budget politics, lack of data, and lack of solution—might explain why the topic of equal access never reached public discussion. One would hope and expect that pubic discussions of an advisory board would be responsive to changes and events occurring in the broader environment and certainly to policies and data that directly relate to the program. However, although immediate attention and discussion about current events and new information is potentially important, it also served to divert attention away from persistent program goals. Below we discuss each factor in turn: how the broader political and budgetary climate, the introduction of policy solutions, and new data might have diverted attention and had the unintended consequence of silencing public discussion about the goal of mainstream access. Political Climate Advocates for the poor were acutely aware of the broader political context, specifically, the national debate about welfare reform. The welfare bill, called the Personal Responsibility and Work Opportunity Act of 1996, was passed in the middle of the deliberative process we observed.3 Similar to welfare reform, MMC reform stresses more individual responsibility on the part of program recipients. Proponents of welfare reform in 1996 (and prior) argued that the state needed to ask more of the poor by creating policies that forced recipients to take on more individual responsibility. Similarly, proponents of MMC often emphasized that the state needed to force recipients to choose an HMO, and HMOs needed to manage recipients’ health care use, so that recipients would begin to utilize the health care system in a more responsible manner. The following is an example of such views as discussed at an MMCC meeting: State legislator 1: Plans should also be managing care. We must control teenage pregnancy and violence. Do plans do anything regarding this behavior?

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DSS bureaucrat: We can’t get at prevention this quickly, but eventually we will press the plans to push on prevention. State legislator 1: For this population, managed care gives them more choices. They need to start taking more control over their lives. DSS bureaucrat: Yes, I agree, this is consistent with welfare reform; this population needs to take more control over their lives and being accountable. (February 2, 1996)

Although this explicit reference to welfare reform happened infrequently, it was not uncommon for participants to express the view that this reform encouraged recipients to act as “responsible consumers” by providing choice but also needed to ask for accountability. For example, when discussing Medicaid recipients under MMC, a health plan representative said in our private interview: I think that these folks need to understand — they might not know that they need to learn about this stuff, but they really do for everyone’s sake. And there’s things like having their welfare check held until they watch a video or something, those kind of coercive kind of things which—I know they’re never going to fly, but I don’t see what’s wrong with that. Really people need to wake up and realize how important this is in a broader context, not just to themselves, but to the health of the state and to their fellow man in the state. So something’s got to be done. And maybe we coddle them a lot in a lot of ways and sometimes I think it might be too much and to their detriment. Yes, we should manage their care. (#50)

Some participants actually blamed Medicaid advocates for past failures, arguing that they have acted too paternalistically and, as a result, inappropriately treated the poor as if they are different from, and less capable than, the rest of the citizenry. For example, in response to a question about DSS HMO marketing policies a health plan representative said: It was really patronizing, condescending, rooted in this sort of notion that Medicaid recipients aren’t quite as capable as other people to make choices and that is, if there is anything that really offended me, pissed me off about this whole thing, was that kind of tone and attitude that somehow, if you gave a Medicaid recipient a McDonald’s cheeseburger, that they were going to choose Oxford

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Health Plan. That’s not what its about and its a shame that there were people who thought that this population would not be able to choose as effectively as the general population. (#49)

Indeed, responses to questions in our private interviews about how Medicaid recipients should be treated under MMC reveal that this larger debate about the poor, their needs, personal responsibility, and concerns about paternalism laid just below the surface of Connecticut’s public deliberations: Yeah, pretty much because they are vulnerable. They have—and— oh man. I just— [Question: Is something wrong?] No, I was just thinking something. A guy who ran against me two years ago just wrote another letter to the editor calling me “an outstanding liberal.” He criticized me—and that’s a criticism always made of liberals—that we want to manage other people’s lives. I would like recipients to make decisions about getting the child to care and make sure the child gets vaccinated. But, I don’t want them to worry about, you know, going to this doctor because he accepts Medicaid. [And] to make the decision about what plan they should be in, and they do have that privilege right now, but it is confusing. Once they’re in the plan, it would seem to me their informed choices should be, you know, the quality of care and so on, rather than eligibility. I don’t want to, you know, tell Mary Smith that she rather be in Blue Cross than in Kaiser Permanente. But I just don’t want them to have to worry about basic things like making sure your kid gets vaccinated. (#63)

Without the interviewer saying a word, this state legislator began defending himself against a paternalistic attack. Although the political rhetoric of welfare reform might come more readily to the fore in a state legislator’s mind, comments from other respondents suggest this larger debate was on many people’s minds. For example, in defending her position that Medicaid recipients typically have greater needs, a Medicaid advocate said: You know, it’s one thing for you and I to be in managed care plans. We know how to call and kind of advocate for ourselves and see other specialists. But I think health care for a lot of people who are poor and have other problems is not a priority. . . . You know, they may have access to all the doctors and services, but doing it is a whole other thing. Because I value health, my family has, my

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children do, we have a different feeling about all of this, and how we go about it in our managed care system. And we get what we need because we know how to do that. I think a lot of people don’t and then it’s not a priority—they have housing issues, and food issues, and clothing issues, and substance abuse issues. It’s not important. (#74)

What is important about this larger debate for understanding the puzzle of public silence is that, for some, the ideology of MMC called into question the legitimate role of advocates to represent the poor. Although many participants disagreed with this view, it is clear that the broader political climate was infused with such ideas, and this might have dampened advocates’ sense of their ability to speak up in a public forum. Not only did the “individual choice and responsibility” ideology infuse the political climate, but there was a sense among the participants that welfare reform represented a serious retrenchment of publicly funded social services. Many believed that the poor would be worse off under welfare reform than they were in the previous AFDC system. Advocates and other participants did not want Connecticut’s MMC to become a form of welfare retrenchment. The answer a CHC representative gave to the question “What do you consider to be the most difficult challenges facing the Medicaid program in Connecticut?” is illustrative of this concern: “With all this talk in Washington and, you know, a much more conservative approach here on some of these issues, just sustaining the program will be a challenge for Medicaid” (#29). This sense of despair that the political climate would not allow the program to reach its intended goals is evident during the only other time public discussion was related somewhat to the mainstreaming goal. Ironically, this discussion focused on the opposite of mainstreaming, that is, the possibility of expanding access under MMC to publicly-funded clinics to provide needed dental care. These discussions emerged out of the MMCC Access Subcommittee—as one might expect given its title—and then was raised at an MMCC meeting for discussion about a specific resolution. Although members of the subcommittee had concerns about access to medical care in general, they focused their attention on access to dental services because this emerged as a serious problem in the MMC program. Very few private, mainstream dentists participated in the program. Although low dental participation was a

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problem before the managed care reform, access actually worsened after the implementation of managed care because dentists in Connecticut were particularly hostile to working and contracting with HMOs. Thus dentists were not only reluctant to take Medicaid patients but also did not want to deal with HMOs. The state attempted to hold HMOs accountable for improved access to providers by imposing specific provider-to-patient ratios. For example, when HMOs did not meet the ratio requirement—that is, the HMO had too few providers—the state would withhold any further enrollment in the plan until the HMO was able to increase the number of physicians willing to participate. These ratios applied to both primary care physicians and dentists. On the dental side, many plans were having difficulty enrolling enough dentists to meet the ratio requirement. As a result, the state withheld additional enrollments into those HMOs (in counties where the HMO was not meeting the ratio requirement). For the dental ratio requirement the only providers that counted were certified dentists. This raised concerns because although all the plans contracted with school-based health centers (SBHCs), which provided a lot of dental care to Medicaid-eligible children, because SBHCs relied on dental hygienists, this access point was not counted. In other words, DSS did not count dental hygienists as “providers” in their calculation of the dental ratio requirement. DSS argued, and many advocates and others agreed, that although dental hygienists in SBHCs provided good and needed services, it was also important that Medicaid enrollees have access to dentists—“just like the general population,” several participants said aloud. These participants wanted to keep the ratio requirement for dentists to force plans to increase the number of participating dentists. Other participants openly disagreed with this perspective in the public forum. They acknowledged that having more dentists in the system would be ideal but were pessimistic that the ratio requirement would make any difference given the longstanding problems of getting dentists to participate in Medicaid. They argued, pragmatically, that by including dental hygienists in SBHCs in the ratio requirement, plans would see the potential of SBHCs for expanding access and SBHCs with dental clinics would be able to expand capacity, thus increasing access to dental services for Medicaid eligible children. For example, in a meeting of the MMCC, a provider representative said, “What about counting midlevel providers such as dental hygienists? If employed in a public health setting, could they

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be counted as providers by DSS in the 1:486 ratio? We could also promote SBHCs” (June 1996). In direct contrast to this view, those who favored only counting dentists in the ratio requirement believed that changing the ratio to include dental hygienists would just be a counting gimmick. Since the plans were already required to contract with SBHCs, it would not “truly” expand access for Medicaid children.4 And in the meantime, they reasoned, it would let the health plans “off the hook.” “I don’t see how this helps improve access,” one Medicaid advocate said in the MMCC meeting. “It’s just a counting issue. SBHC and CHCs are already at capacity, so if anything it helps the plans that have had trouble getting dentists” (June 1996). After discussing the issue in the MMCC’s June meeting, a member of the council presented a resolution in July 1996 from the Access Subcommittee that called upon the Department of Social Services to promote the use of SBHCs—a publicly funded program staffed largely by dental hygienists. Obviously, the intent was to increase the use of dental services for Medicaid children. After the resolution was presented, the following discussion ensued: State bureaucrat (#90): I wonder about a professionalized dental care system which encourages particular types of care in certain venues. I wonder whether or not this might create a two-tiered system. Whether adoption of this type of resolution will then let dentists in private offices off the hook. State representative (#61): Having worked in a SBHC, I can say unequivocally that it is not a two-tiered system. It happens to be comparable. Full services are provided, and when needed they are referred on to a private dentist. At no time do I feel that their services are compromised. In fact, what would happen if this method was not offered is they would get no services at all. State bureaucrat (#90): Again, if you look at the current arrangement, there is already a contractual requirement with the managed care plans to contract with the SBHCs. I just raise the issue of whether it is right to go further with this emphasis. I think SBHCs do a good job; it is just a question of particular emphasis. State representative (#61): But private dentists don’t participate. We know what the problems are, and this is a strategy to solve the problem. It is an adjunct to that. HMO representative (#42): I understand that SBHCs work, but this takes pressure off private providers and managed care plans.

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Medicaid advocate (#17): As I said in the beginning [when she presented the resolution], this was seen as part of an overall strategy recognizing that [getting dentists to participate] is incredibly problematic. And, in fact, I think we recognized this in the first place when we discussed carving out dental services [separating dental services from the MMC program]. In a sense, by including it [dental services in the capitation rate] we hoped, in a way, that we could make the managed care plans accountable for providing dental services. But they have the same problem with getting providers to participate that people in the Medicaid program had before. State senator (#58): One of the things that comes to mind for me is that there are no easy answers. With Medicaid, people are not getting the health care that they need, they haven’t ever, and they still aren’t. (July 19, 1996)

Given the history of Medicaid, and of health care services to the poor in general and the political climate around welfare reform, it is perhaps not surprising that participants, as the state senator suggested, were skeptical and pessimistic that any real change in mainstreaming would occur. Indeed, participants, even those who disagreed with the resolution in principle, decided to focus strategically on what they thought they could achieve: an increase in the capacity of public clinics for Medicaid recipients. All but one member of the council voted in favor of adopting the resolution, though many more members argued against it. Then, after the vote, their attention was diverted to other matters. The discussion about a twotiered system and how to hold plans accountable for provider participation to create a one-tiered system—topics most participants said they cared about privately—was again dropped from further public discussion. Budgetary Climate Along with a sense of constraint imposed by the national political and policy context, the Connecticut General Assembly was having its own debate about the next fiscal year budget. In almost every budget battle, when the legislature is trying to expand the budget for certain programs, legislators are often forced to look for where program funding can be cut or where program “savings” can be achieved (Cobb and Elder 1981; Dodd and Oppenheimer 1997; Schick 1983; Sinclair 1990; Wildavsky 1992; White 1994). Indeed, many participants described the adoption of MMC as budget driven: “To me, what motivated the legislature and the budget

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folks was something had to be done to try to bring this thing under control from an appropriation perspective. . . . I think the sort of critical piece from the legislators perspective was being able to claim credit in the budget for savings, which resulted from the creation and implementation of the program” (#49). Two years later, when the state was looking for budget “savings” yet again, the Medicaid managed care program was on the table. In their search for budget savings the issue was raised as to whether the program could save more money by moving to competitive bidding. It was quickly decided that the program could save money by moving to competitive bidding, and the question became how much. As a result, the general assembly passed legislation stating that the MMC program would save $7 million dollars and DSS should consider the use of competitive bidding to achieve such savings. Of course, it is not surprising that the deliberative body would divert its attention to this new information—that DSS had to find $7 million of “new” savings in the program. A state senator and chair of the MMCC commented at a council meeting, “The council should follow this [saving $7 million] closely. The program seems to be out of the turbulence it had been in and this policy shift could create further turbulence” (June 1996). The design of the competitive bidding policy was discussed in every meeting after this. Some participants believed the state could save an additional $7 million because greater efficiencies from MMC had yet to be realized. However, to the majority of participants, the thought that Medicaid could save more money without hindering quality or access was ludicrous. Most believed the program was chronically underfunded. Thus any talk of “savings” was to them code for welfare retrenchment. Amid budget politics, the following pessimistic comment by a provider representative about the goals of the program was fairly common: “How can you do this and expect the product to be high quality? I don’t think they really cared a lot about that. I think they just wanted to demonstrate that they could cut costs and there was a lot of pressure to develop this program. Again, I’m not against Medicaid Managed Care, I was against the way in which the process was developed . . . to cut the dollar and the cost of the program” (#77). Most participants in the deliberative process—including health plan representatives, state bureaucrats, and Medicaid advocates— felt frustrated by this move in the state legislature. Yet when a representative from DSS reported in a public MMCC meeting that

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“a competitive bidding process would be the best method to achieve the $7 million in savings,” no other participants in the deliberation pushed for an alternative solution. Indeed, there are no silver bullets for how MMC systems can save money, especially without reducing quality and access. The only other option for DSS was to lower the capitation rate paid to HMOs, but participants were already concerned that the rates were too low. Better for DSS, the state bureaucrats reasoned, to ask plans to compete over the rates and then to hold plans accountable for the lower rates they themselves submitted. Participants did not push for another policy solution, but they were not passive. Participants were very concerned that they be part of the planning process around the competitive bidding policy. They focused a good deal of their attention on the competitive bidding issues, the capitation rates, and the collection of data to measure the quality of care provided so that the state could hold plans accountable in a reasonable way. The broader political environment and the external shock of a budget process might have contributed to this sustained focus and diverted public discussion away from other program goals, such as mainstreaming, to focus heavily on the costs of the program. Instrumental Responsiveness to Problems and Proposed Solutions The discussion above illustrates how a constrained budgetary climate can focus attention on cost control issues—perhaps at the expense of devoting public discussion to other goals participants care about. It also illustrates how a specific proposed solution to a problem, such as the competitive bid policy as a solution to reducing Medicaid expenditures, can focus attention on an issue—no matter how minor—and as a result divert attention away from other concerns. Another example of this was the Access Subcommittee’s effort to increase dental participation in the program by standardizing administrative practices among HMOs. Because each of the eleven HMOs in the program required a different administrative process for dentists to contract with their HMO, dentists often commented that the administrative process associated with the MMC reform was overly burdensome. Subcommittee participants worked with both dentists and HMOs in an effort to create a common administrative process across plans so that the administrative burden would not deter dentists, who might ordinarily participate in the Medicaid program.

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Of course, the main purpose of managed care is to “manage” patient care, and HMOs use their administrative forms as a way to keep track of patient utilization and provider practices. Thus the way providers report information to HMOs is extremely important to the HMO and often considered proprietary information. As a result, what might at first blush appear to be an easily implemented policy solution turned out to be difficult because HMOs participating in Connecticut’s program were very resistant to creating a common administrative form. As a provider representative (not a dentist) announced publicly to the MMCC, “The access problem for dental services has been grappled with in the Access subcommittee. . . . The subcommittee is trying to develop one claim form for all dental services and one credentialing form for all plans and providers. It has not been easy” (May 12, 2006). After the Access Subcommittee’s success in securing a common administrative form for dentists, the behavioral health subcommittee also began working on a common administrative form to increase participation among mental health providers in the program. Indeed, advocates with concerns about lack of providers funneled their interests into this very specific solution. From an instrumentalist perspective of wanting to do something in the near term to address a problem, this focus makes sense. However, note how this specific solution actually took them far afield from their main access concern and stated goals for the program—to secure mainstream care for Medicaid recipients. Similar to the resolution on SBHCs and dental hygienists, this solution was focused on merely maintaining the status quo prior to MMC reform. More important, the focus on this solution negated a broader discussion about the topic they really cared about: how MMC could live up to its promise of offering mainstream care. Discussing solutions in the public forum, no matter how minor, took precedence. As a result, solution-focused discussions appeared to be more worthwhile to participants than “aimlessly discussing their concerns.” Instrumental Responsiveness to New Data Similar to a change in policy or the introduction of a new policy approach, when new data were presented to the MMCC on how Medicaid recipients were choosing HMOs, the nature of the public conversation changed dramatically. In May 1996 the director of the agency responsible for enrolling Medicaid recipients into HMOs presented his report to the council. For the first time, he was able

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to provide information on how many Medicaid recipients switch plans in any given month: between 16 and 20 percent. Interestingly, all members interpreted the rate with concern for two reasons. First, the main reason given by enrollees for switching plans was, not surprisingly, that her or his provider was not in the plan. Council members interpreted this as evidence that recipients were not making informed choices during initial enrollment. Second, members also interpreted the switch rate as evidence that recipients did not know how to use the HMO grievance process. In response to these new data, the director of MMC for DSS suggested that recipients should not be allowed to switch—they should be “lockedin” to their plan choice for at least a six-month period. When this was first presented in May, many participants voiced reservations about using a lock-in policy. However, after asking for more data on why recipients switch plans so often, and discussing the costs and benefits of a lock-in policy over a six-month period, a consensus emerged that a lock-in was desirable. After numerous deliberations, several different arguments in favor of a lock-in emerged. First, some Medicaid advocates, especially those with a legal background, expressed concern in the deliberation that recipients were not using the grievance procedure process. There was concern that if dissatisfied enrollees switch plans, rather than use the grievance process, HMOs will never be held accountable. Obviously, this argument puts little faith in competition between HMOs for enrollees as a method for holding plans accountable and believes you need the regulatory force of the legal system for plans to respond. Although a state bureaucrat responded, “The ability to move from plan to plan is the ultimate quality control,” few participants thought competition would be enough to hold plans accountable. When we asked in our private interviews with participants, “How far do you think competition will go in terms of assuring quality of care?” 64 percent were skeptical that competition would assure quality of care for Medicaid recipients. Although health plan representatives and state legislators as a group were more likely to express hope in competition, the vast majority of participants expressed doubts that competition alone would be adequate to assure quality. These doubts emerged in the public deliberation around the issue of health plan switching. Second, HMO representatives and DSS officials argued (again) that Medicaid recipients are “just like you and me” and therefore should be locked in. Because the majority of Americans receive their

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health insurance through their employer, and—if given a choice at all—are usually only allowed to switch their health plan once a year, many participants wondered why Medicaid recipients should be given more choices. The following refrain was often heard in the public deliberation: “We only get to switch plans once every year. Why should they get special treatment?” Third, many participants argued that continuity of care would be better under a lock-in. If HMOs knew that their Medicaid enrollees would be in their plan for at least six months, the plans would have stronger incentive to provide preventive services. In contrast, if 20 percent of enrollees switch every month, there is a perverse incentive to pocket the capitation payment from the state and hope (or worse discourage) enrollees do not utilize health care services. A clear consensus emerged on this point; everyone agreed publicly, and in our private interviews, that a lock-in would provide more continuity to the medical care Medicaid recipients receive. Finally, there was widespread agreement that a lock-in would reduce administrative costs for the state. Many voiced the opinion, and there was no voiced opposition to this point, that it was too burdensome for the state to administer month-to-month plan switching among enrollees. Obviously, under a lock-in policy the grievance procedure process becomes much more important. Participants were concerned about this and openly discussed how the state should make sure the grievance procedures are accessible and adequate for Medicaid enrollees. We detail the development of these arguments in favor of a lock-in policy to illustrate not only the power of data to focus attention but also that these were able participants who brought a great level of expertise and seriousness to the public discussion. One cannot easily conclude that participants did not discuss the mainstreaming goal because they did not take the advisory board and subcommittee meetings seriously or viewed the process as a token exercise. To the contrary, this example shows how the consensus over the lock-in policy emerged in a very deliberate fashion. Collectively, participants responded to new data on health plan switching; these data raised questions and concerns and so they asked for additional, clarifying data; over the next five months they considered the meaning of these new data about why enrollees switch and debated whether the lock-in policy was an appropriate and adequate solution. They decided it was, but they emphasized the need

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for a better grievance procedure process. On the one hand this is a positive example of how public discussion can helpfully respond to implementation problems, but on the other hand this responsiveness to new data and the ensuing debate about health plan switching (which was most applicable to 20 percent of program recipients) might explain why the public forum never returned to a discussion about the adequacy of those plan choices.

CONCLUSION This chapter details the puzzle of public silence and offers some suggestions for why participants did not discuss the goal of mainstream access even though the majority clearly thought it was an important challenge that should be addressed. We offer several possible explanations but argue that no one factor resolves our puzzle. Certainly the public and budgetary climate dampened the hopes of many participants that significant progress could be made on attaining mainstream access for Medicaid recipients. But many were equally pessimistic that the quality of care provided could also be improved under reduced funding, and yet they continued—under the same welfare ideology and despite their privately expressed fears—to fight publicly for the importance of improving the quality of care provided to Medicaid recipients. Moreover, the lack of a solution likely made it more difficult to discuss mainstream access, but this doesn’t explain why participants did not propose a specific solution to hold HMOs accountable for expanding access to providers. The provider-to-patient ratio requirements were perceived by some to be an appropriate policy solution for holding HMOs accountable for “adequate” access, but no one argued that this ratio requirement provided any guarantees that Medicaid recipients had expanded access to mainstream providers. Indeed, many participants privately questioned the validity of HMO provider lists, suggesting that the physicians listed were not truly available to take on new Medicaid patients. “It’s the same old providers taking care of the vast majority of Medicaid patients,” said an advocate (#16). But this raises another important question: Why, if they questioned the validity of the HMO provider lists, did they not advocate for data collection to better understand physician participation in the MMC program? This was exactly the tactic used for attempting to improve quality. There were no data on health outcomes

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for Medicaid recipients to determine whether they were getting adequate quality, so participants focused their efforts on data collection. Thus although the introduction of new data and new solutions tends to focus public attention on those specific issues and might have diverted attention away from the mainstreaming goal, this does not explain why participants persistently raised the quality monitoring issue that similarly lacked data and a clear solution to focus the discussion. Moreover, why were participants eager to keep a sustained conversation about costs and capitation payments on the public agenda when there were no easy solutions about how to increase funding or change the reimbursement methodology? In the case of mainstream access, perhaps it was the combination of all three factors that significantly stymied public discussion around the goal of improving access to mainstream medical care. Nonetheless, an examination of the contribution of each factor toward stifling public discussion, when compared to the topics that were discussed, suggests a lack of explanatory power. In other words, although the institutional pieces fill in some of the public silence puzzle, several pieces are still missing. To find those missing pieces, we turn next to documenting the Medicaid policy network and show how MMC reform changed interests and social interactions within the network and made open discussion about mainstream access particularly difficult.

5 Medicaid’s Policy Network and the Ties that Bind NONPROFIT ADVOCACY AND SOCIAL INTERACTIONS

Concerns about the state’s budget, a political climate that made it difficult to criticize the new program, a lack of data to measure mainstreaming, and specific solutions that diverted attention from larger issues all contributed to the public silence over mainstream Medicaid access in Connecticut. Yet as we concluded in the previous chapter, these factors were not enough to prevent advocates for the poor from discussing equally tricky issues such as the state’s capitation rate or quality assurance, so there must be other reasons for the striking absence of public debate. To fill in the missing pieces of the public silence puzzle, it is crucial to understand how MMC reform itself changed participants’ interests and social interactions within the policy network. These changes significantly hindered the ability of advocates to represent the interests of the poor on the issue of mainstream access. If we look closely at the participants of Connecticut’s public forums, we find that three of the six main groups included— Medicaid providers, Medicaid advocates, and Medicaid consumer representatives—have extensive experience with poor children and their families enrolled in the Medicaid program, and they all have a strong and integral tie to the world of nonprofit health and social service organizations. Even many participants from the other three groups—health plan representatives, state legislators, and representatives of state agencies—have longstanding ties to nonprofit health care organizations. The main reason for these ties stems from private physicians’ lack of willingness to care for Medicaid recipients and the state government’s consequent reliance

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on community-based nonprofit health organizations to provide Medicaid covered services. Indeed, one of the main strategies Medicaid advocates use to help the poor is to work closely with the numerous nonprofit organizations that provide those services and lobby state government to increase funding to these nonprofit organizations. As described in chapter 2, this is not a new phenomenon, nor is it unique to Medicaid (Berry and Arons 2003; Milward and Provan 2000, 2003; Provan, Isett, and Milward 2004). Since the trend toward significant use of nonprofits to provide government-funded health and social services began in the 1960s, nonprofit delivery networks have been established and, often, nonprofits enjoy longstanding political relationships with local government officials and other actors in the policy network (Berry and Arons 2003; Milward and Provan 2000, 2003; Provan, Isett, and Milward 2004). Yet relationships among actors in the Medicaid network (who were also the participants in the public forums) changed after the introduction of Medicaid Managed Care. The purpose of this chapter is to explicate those changes and to show how and why those changes had important implications for public discourse. The chapter consists of four main parts. First, we document the characteristics of Medicaid’s policy network prior to MMC as a situation of mutual dependence between state government and Medicaid advocates and providers. Second, we discuss how the introduction of MMC changed the policy network by bringing in new actors and moving from collaboration to competition among many actors. Third, we describe how, in response to MMC reform, Medicaid advocates and providers became politically active on a number of fronts. Besides lobbying for the creation of an advisory board with more open and inclusive participatory process, as discussed in chapter 3, they also fought for an oversight body and for particular Medicaid providers to have various types of “protected status” under the new reform. Finally, in the fourth section, we show how this political lobbying and strong collaborative ties to Medicaid providers came with costs to how they were viewed and how they were able to advocate in the public forum. In particular, even advocates from organizations with no Medicaid funding, and therefore with no particular self-interest in securing a special role under MMC reform, lost their legitimate voice for the poor especially around the issue of unequal access.

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RESOURCE DEPENDENCE AND POLITICAL ACTIVITY As did other nonprofit health care providers across the country, nonprofit health care providers in Connecticut with significant Medicaid funding devoted substantial political effort to enhancing and securing those funds before and after MMC reform. In our interviews nonprofit representatives described significant political activity to improve “their partnership with the state” because they believed their organization could better serve client needs under increased financial resources. It wasn’t a one-way street, however. Connecticut’s Department of Social Services asked for input from nonprofit Medicaid providers because they relied so heavily on these institutions to provide the bulk of services to Medicaid patients. Because of Connecticut’s heavy reliance on a relatively small set of “Medicaid providers” who provided care to 85 percent of Medicaid recipients, Medicaid providers had almost no active opposition in their role as advocates. Indeed, DSS encouraged community health centers and other Medicaid providers to be politically active. This encouragement came through clearly in our interviews when we asked participants how they became involved in Medicaid managed care reform. Every one of the advocate and nonprofit service providers mentioned in our interviews that they were already actively working with state agencies on various Medicaid-related initiatives prior to the enactment of MMC. Illustrating the wealth of collaborative projects between Medicaid advocates and providers and state agencies, one provider/advocate noted, “I coordinate the local Healthy Mothers/Healthy Infants Coalition, and also I sit on the state steering committee for that. And I was also funded to do what’s called the X Action Plan for Infant Health, and with the AFDC population going first, I became involved from the very beginning. . . . We became pretty involved as far as getting the information out here locally before it was actually happening” (#11).1 Collaborations within the network between advocates, such as those working for foundations, and Medicaid providers were common as well: We were already very involved with current Medicaid providers. [When MMC was introduced], we wanted to make sure the providers were not hurt by these changes because the providers are our grantees. Our main concern was maternal and child health

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and making sure that certain services would not be diminished, because [we] had been in accessibility and delivery of care [related to Medicaid] for the past ten years. (#7, advocate, nonprofit foundation)

These collaborations among nonprofit organizations within the Medicaid policy network are not unusual. Several studies find that “organizations often work together to help overcome resource deficiencies, decrease uncertainty in their environment, and gain influence” (Provan, Isett, and Milward 2004, 174-75). Many argue that collaboration is particularly important for fragmented delivery systems to improve patient outcomes (Alter and Hage 1993; Provan and Milward 1995; Provan, Milward, and Isett 2002). Within the Medicaid delivery network, where many provider organizations do not address the full range of client health needs, collaboration had been encouraged for a long time to improve access and continuity of care. Given this stable interdependent network, it is not surprising that when the state moved toward MMC, the collaborative relationships and two-way dependency (between the state and nonprofit organizations) changed. The MMC reform adopted in Connecticut, and in many other states, was primarily a contracting regime change in which the state switched from paying Medicaid providers directly for services rendered to contracting with HMOs. In Connecticut’s case, the state actively recruited commercial HMOs to contract with the state to provide services to Medicaid recipients. This changed the constellation of actors in the policy network and traditional Medicaid providers’ favored position in that network. Moreover, MMC introduced the new idea—completely antithetical to the notion of collaboration that was emphasized for so long—that organizations should compete to better serve Medicaid enrollees (see Grogan and Gusmano 1999 for the impact of MMC on “safety net” nonprofit organizations).

THE IMPACT OF A CONTRACTING REGIME SHIFT ON THE NETWORK In 1992, when DSS was feeling pressure to move toward managed care, the state Medicaid director created a Medicaid managed care advisory committee composed primarily of representatives from the

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managed care industry. According to DSS officials, the primary purpose of the advisory committee was to provide the department with feedback about the design of the new program and, in so doing, generate interest and commitment among HMOs to participate in the program. “I put together an advisory committee of all of the managed care companies in Connecticut in order to get them interested,” a DSS representative noted. “One of my concerns as a medical director was that I would throw a party and nobody would come. So I wanted to make sure we designed the program in a way that private companies would, in fact, be willing to participate” (#100). Every DSS representative we interviewed confirmed that they intentionally created an industry-focused group. Although the advisory committee officially included representatives from the community health centers (federal waivers at that time required the inclusion of federally qualified health centers in any type of Medicaid managed care reform) and one Medicaid advocate in addition to the HMO representatives, the Medicaid director at the time described involvement this way:2 “It was the state and private health plans. What I wanted to do was get the basic design kind of laid out with them first. We had plans to have a sort of advocacy group for input as well, but . . .” (#100). The department did not want to involve a broader set of actors until they had developed the basic design of the program, because they believed that opposition to managed care from Medicaid advocates would have poisoned the atmosphere and discouraged plans from participating in the Medicaid program. Clearly, by DSS’s own admission, this advisory committee did not represent an open or inclusive process. DSS’s use of these industry-focused meetings to decide on the broad contours of managed care reform was mentioned by many participants in our interviews. This quotation from a Medicaid provider is exemplary: “The state operated on the terrible fear that no one would take this product. I think to a flaw, to some degree, though there’s a logic going in. They were very worried that they wouldn’t have any takers from the industry. And so what played first and foremost into their mind were potential Managed Care organizations” (#32). It is clear that DSS thought it would fail its main goals—cost, quality, and mainstreaming—if commercial HMOs did not participate. Although cost control was clearly paramount in their decision to create a risk-based mandatory managed care program, access to

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more providers was repeatedly mentioned as one of the key benefits that commercial HMOs could bring. The Medicaid director in charge of designing the program at the time, said, “Quite frankly, I thought that the access to services would be better under a private managed care system than under the Medicaid system, which had such difficulty getting physicians, pediatricians in particular and obstetricians, to sign up” (#100). According to DSS, Medicaid-only HMOs (those created by the traditional Medicaid providers) did not have the resource capacity or the contacts with private physicians to expand access. The department’s view illustrates how the goal of mainstreaming challenges us to ask what set of providers should be available to the poor. Should the state mandate that all licensed providers take Medicaid patients? Or, in the MMC context, should the state mandate that commercial HMOs require their contracted physicians to take all plan members regardless of whether they are members paid through Medicaid or some private-paying scheme? Or should the state simply require that Medicaid recipients have access to the same number of physicians but not necessarily the same set of physicians as private-paying patients? In keeping with the nation’s longstanding tradition of not requiring physicians to take care of the poor, Connecticut decided, and almost every other state implementing MMC did as well, to require access to an adequate number of physicians.3 Because adequate access was defined in this way, the mainstreaming goal under MMC was not just about how to expand access to private providers, who had not traditionally participated in the Medicaid program, but also about whether and how traditional Medicaid providers should be protected under this competitive reform. Given that Medicaid providers’ financial solvency depended so heavily on the steady flow of Medicaid funds, it is not surprising that they all responded strategically to MMC reform: Some fought for protected status, CHCs created their own HMOs to compete on par with commercial insurers, and others worked at securing the best contract as possible with HMOs. Most participants understood the strategic actions of Medicaid providers as naturally self-interested under this new competitive reform. Although several participants acknowledged Medicaid providers’ experience in working with Medicaid patients as an important “competitive” attribute, most agreed that this experience no longer allowed them to act as representatives of the poor under this

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competitive regime. Under the new logic and rhetoric of MMC, Medicaid providers could claim to understand patients’ needs more than private physicians (or commercial HMOs), but the decision was now ultimately in the hands of Medicaid recipients to choose which HMO they would like and consequently which physician they preferred. In contrast, Medicaid advocates, who did not work for a service or provider organization, could continue to provide an important “objective” voice for the poor because they had no financial interest in the outcome of MMC. Indeed, by including them on the advisory board and its various subcommittees they were asked to play that role. Because the vast majority of participants (88 percent) agreed that it was important to provide Medicaid recipients a choice of “mainstream” HMOs, and all the Medicaid advocates mentioned in our private interviews that inclusion of commercial HMOs was necessary to expand access, we expected them to discuss the mainstreaming goal in the public forum, especially when they were concerned that expanded access was not occurring as they had hoped. Yet as shown in chapter 4, they did not raise the issue. A Medicaid advocate explaining her view about expanding access gives a glimpse of why this happened: From a very, very, very elementary, very basic perspective, one of the reasons that advocates did support the waiver, ultimately, . . . was because we believed that there would be enough people working together in the state of Connecticut to get the capacity of the system to increase. That was sort of the only reason to do this, . . . to increase . . . access . . . by increasing the number of nontraditional [private] providers in the network. But not at the same time decreasing the number of traditional providers in the network. (#15)

Although Medicaid advocates supported the inclusion of commercial HMOs, the last sentence of the above quotation is noteworthy because it illustrates how they also believed strongly that these HMOs should not substitute for traditional Medicaid providers. This concern about substitution, and the Department of Social Service’s preference for commercial HMOs, expressed by involving them in the early decision-making process and intentionally excluding the traditional Medicaid advocates and providers, set the stage for advocates’ strategic response to focus almost solely on protecting traditional Medicaid providers and services under reform. Given

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this response, many participants in the public forums equated advocates’ interests with Medicaid provider interests and implied in the public forums and said explicitly in our private interviews that traditional Medicaid advocates no longer had a legitimate claim to represent Medicaid recipients.

ADVOCATES’ POLITICAL RESPONSE TO MMC Medicaid advocates pursued three main strategic responses to the introduction of Medicaid managed care: they fought for a more open, inclusive advisory board to oversee the design and implementation of MMC; they sought legislation to protect Medicaid recipients’ access to certain Medicaid providers; and they fought to create an oversight body to monitor quality of care under MMC. Because we described the process of creating the advisory board and its subcommittees in chapter 1 (and a bit more in chapter 3), we do not repeat that discussion here. However, we do discuss the remaining two strategies (see also Figure 5.1 for a depiction of important changes embedded in the MMC design). Protect Access to Medicaid Providers Medicaid managed care introduced a great deal of uncertainty for traditional Medicaid providers about how best to interact with participating HMOs. A central concern in Connecticut (and in every state that sets up a MMC reform) is whether certain providers should be designated as “essential.” This designation mandates HMOs to contract with specific providers because the availability of their services is deemed to be absolutely necessary for Medicaid enrollees. In this way, “essential” status guarantees that all Medicaid recipients have access to such providers, regardless of which HMO is chosen. Two types of Medicaid providers were given “essential provider” status in Connecticut: school-based health clinics and child guidance centers, which provide mental and behavioral health care services for children. Both provider groups exerted significant lobbying efforts to secure this special status employing the following claims. School-based health clinics were considered essential because their prime location enables children who might not otherwise have easy access to care to receive it during the school day, whereas child guidance centers were considered essential because of their experience in working on behavioral health issues with poor

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Figure 5.1 Structure of Connecticut’s Medicaid Managed Care System Advisory Board: MMCC

Department of Social Services (Medicaid Division)

Monitoring Group: CCHP

Full-risk Contracts: 5 Medicaid-only HMOs: 2 CHCbased HMOs

3 Hospitalbased HMOs

Mandated Contractual Funding Links:

6 Commercial HMOs: 2 Default HMOs

4 Local and Statewide HMOs

Essential Providers: School-based Clinics Child Guidance Centers

Optional Contractual Funding Links: Non-Essential Providers with Special Concern: Community Health Centers Public Dental Clinics

Carve-out Providers (No Need for Contractual Links) Family Planning Services

All Other Providers: Private Physicians and Specialists in Various Practice Settings

Legend: New Actors to the Medicaid Network Advisory/Oversight Role Mandatory Connection

children in difficult circumstances—a level of experience no other provider, they argued, could claim to have. With the same type of “protection” arguments in hand, that family planning clinics provide essential services to Medicaid recipients not available elsewhere, Medicaid advocates also fought and won to have family planning clinics “carved out” of the MMC reform.

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This meant that Medicaid recipients could go directly to family planning clinics just as they always had, and the clinics would be reimbursed directly from the state just as they had been under the traditional Medicaid program. It was natural for Medicaid providers to fight for protected status under MMC. They had a number of concerns. First, they worried that the commercial HMOs, which they never had a relationship with, would not contract with them. Second, they were concerned that under HMO contracts the plans would deny needed services— due to either a lack of understanding of the special needs of Medicaid clients or the profit motive of commercial HMOs. And finally, they were concerned that their reimbursement rates, which were already low relative to the private sector would actually decrease under HMO contracts since the state specified no reimbursement requirements. It was also natural for Medicaid advocates—those working for nonprofit organizations without a service component—to fight for protected status for Medicaid providers stemming from their longstanding collaborative ties. Because most advocates fight to improve health services for all the poor, not just Medicaid-eligible poor, they understood the crucial role Medicaid providers played for nonMedicaid patients and wanted to make sure MMC did not hinder Medicaid providers’ ability to serve the uninsured. In addition, most advocates had been working on Medicaid policy for a long time, and remembered the failure of previous state efforts to expand access to private physicians. Although they were hopeful and wanted MMC reform to work, they were also skeptical because previous reform efforts had failed. This skepticism led to advocacy for Medicaid provider protection because they worried that commercial HMOs would eventually drop out of MMC (just as private physicians had in the past) and in the meantime Medicaid providers would be hindered and access to care for Medicaid recipients would actually be worse than in the pre-reform period. Establish an Oversight Body Besides lobbying for the protection of Medicaid providers, advocates also fought for the creation of an oversight body to assure that needed medical and preventive services would be maintained for children. Indeed, advocates were successful in convincing the Connecticut General Assembly to appropriate $5.2 million to establish the Connecticut Children’s Health Project (CCHP) to monitor the

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impact of MMC on Medicaid children. The CCHP was created with the intention of building on a pilot project funded by the state and a private Connecticut-based foundation4 for early childhood health prevention and outreach.5 In particular, the pilot—called Hartford HealthTrack—used an aggressive outreach strategy to improve participation in the Medicaid program by Connecticut children residing in Hartford (the largest city in Connecticut) and attempted to expand access to well-child care services under the traditional Medicaid fee-for-service (FFS) program. During the pilot period the number of children receiving annual health screenings increased by 30 percent. Given this increase in preventive health services for children, the HealthTrack program was viewed as a tremendous success by many Medicaid advocates and policymakers in the state, and many thought the program would be expanded to the rest of the state in 1995. However, when advocates presented DSS with a proposal to incorporate the HealthTrack outreach program into its MMC program design, the effort was met with little enthusiasm. DSS officials believed the program was no longer necessary under MMC because participating HMOs would (as a contractual requirement) conduct outreach and provide adequate access to preventive health care services for Medicaid children. In their view a statewide HealthTrack program would be a duplication of effort in a Medicaid managed care environment. Advocates for HealthTrack argued that a statewide program was necessary under managed care because the HMOs would not have enough experience conducting outreach for this population and might not have enough incentive to maintain or expand access to preventive or well-child care services. Moreover, advocates were concerned about the ability of DSS to take on the additional responsibility of monitoring these services at the same time they were putting a new program in place. Medicaid managed care involved a significant increase in the number of tasks required of DSS. As one proponent explained, “We didn’t think DSS would be able to manage and we thought (and, as it turned out, I think we were correct) that they would have their hands full just getting it off the ground. You know, setting up the bidding process for the health maintenance organizations, setting up all the procedures and all of that business” (#45). Clearly, Medicaid advocates and providers distrusted DSS and the health plans to do outreach and provide appropriate preventive

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care to Medicaid clients and worried that the MMC reform would allow Medicaid providers to wither by the wayside. Because advocates and providers had been key players in the Medicaid policy network for so long, they had strong established ties to legislators in state government and were successful in influencing the shape of MMC. Several Medicaid advocates acknowledged their influence in our interviews: We were involved in the beginning even in the negotiation to establish the Children’s Health Council. We were involved in the design. We have a commission member who is the head of Pediatrics at the Children’s Hospital on the Managed Care Council. And we have a staff person who is legislatively assigned to all legislators on public policy who worked in depth on health issues. And then I sit on the Children’s Health Council . . . and then we also had an ear to the community because we work, probably once a week, with virtually every hospital in the state, different staff members. And we run the parent training institute for the state, so we’re in sixteen cities working with parents weekly. So we had an ear to what was and wasn’t happening, what the concerns were, which we were funneling where appropriate. (#20) I think there are a lot of opportunities to make change. The fact that there’s a Medicaid Managed Care Council . . . and so there’s a lot of quality control here and a lot of access. The fact that the department [DSS] has been very open to a lot of changes that people want. The fact that the Children’s Health Council is outside of government, even though it’s funded by government, that’s another sort of check and balance in place. . . . Yes, I do believe [our views] were heard. (#12)

DELIBERATIVE COSTS OF STRATEGIC POLITICAL INFLUENCE Although Medicaid advocates’ ultimate concern was to expand access to multiple types of providers for Medicaid recipients, they focused their lobbying efforts on protecting Medicaid providers and protecting the provision of particular types of services. No doubt this focus emerged out of the fact that the state clearly needed no encouragement to expand access to commercial HMOs but showed no inclination to protect Medicaid providers. Thus advocates log-

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ically invested their political effort where they perceived the need to be. Although logical, this one-way advocacy to protect traditional Medicaid providers and services came with costs, affecting how well they could advocate for the poor in the deliberative forum around the issue of expanding access. Advocates’ lobbying efforts left the impression among many participants in the new Medicaid policy network that advocates were biased and ultimately interested in maintaining the status quo. Although many representatives from state agencies, some legislative staff, and health plan representatives distrusted Medicaid advocates and providers from the very beginning, advocates’ lobbying efforts confirmed and intensified their views: We had plans to have a sort of advocacy group for input as well. Though I knew full well that they would be far less reasonable to work with, and so it wasn’t my first priority to involve them. And certainly they did fight, tooth and nail, against managed care with the very misplaced belief that it would compromise access to care, as though people on Medicaid had decent access to begin with. (#100, DSS representative) I don’t know that the old system of fee-for-service didn’t work more to the benefit of providers than it did to recipients in that I don’t know that we ever were taking like a $400 million buying power in trying to leverage the best purchase in terms of health care for our entitled population. I think Managed Care at least offers you the opportunity to do that as opposed to being manipulated by this or that provider group to carve up that $400 million into whatever works to their best advantage. I think, as you heard in terms of what the policy discussions were about Managed Care, we were manipulated by a lot of those same advocacy groups anyway. I think we insulate ourselves a little bit from that under Managed Care, but not entirely. (#97, DSS representative) One of the things that astounds me about this whole Medicaid system is the network of paid advocates around maintaining the status quo. And there are advocates with a significant amount of political sophistication who are used to going to the legislature and lobbying, used to going to the administration and lobbying, and used to going to regulators for their particular cause or concern. I am amazed, constantly amazed by this, frankly, what I would describe as a sort of white suburban infrastructure around welfare policy. Guys who live in Glastonbury work for an agency. Women who

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live in West Hartford are full-time Medicaid advocates and I have thought generally that often times those folks are more interested in the preservation of their own, not only their own piece of the action, but their own sort of jobs which will make for the preservation of the program, than they are about seeing real progress in the Medicaid program or advancing the cause of the people on Medicaid. (#49, commercial HMO representative)

Advocates were also concerned that their focus on protecting Medicaid providers meant they were less able to focus on Medicaid recipients. One mentioned how it was difficult to advocate purely on behalf of the Medicaid “consumer”: “I think there were certain views that were not heard, and I was particularly concerned about the consumers not being educated and not having any input into the design of the program. There was not a whole lot of reaching out to the provider community for input and certainly not much, if any, that I know of, outreach to the consumer community” (#19). This advocate reflected further, based on her previous experience heading up a nonprofit service organization, that most of the time she was forced to focus on securing government funding or securing a role under a policy reform and there was not much time left over to focus on providing a voice for consumers: I used to be a community action agency director. . . . Our agencies were the first to get block grants under Reagan in 1980. I spent a year lobbying, educating, and informing important people in the state of the necessity to preserve our funding. A whole year of energy went into looking at the worst case scenario, what can we salvage, a lot of energy going into just keeping the doors open, not into doing what my mission was to do, to provide services to poor people. . . . I think that’s the piece that’s missing is the consumer base. . . . What we have now are professional advocates, myself included, that are speaking for consumers, but we’re not really spending the time to build the constituency that’s really most affected by this. (#19)

Because advocates’ main lobbying effort was to create an oversight body to monitor quality and protect Medicaid providers’ status, most participants involved in the deliberations logically concluded that advocates and providers alike wanted to maintain the status quo. Even Medicaid advocates sometimes merged their efforts and interests together. “So, you can imagine that we were a group of

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providers and advocates,” said one advocate, “and it’s been difficult because I think we were very skeptical and yet we wanted to maintain a certain positive presence and input, and I think to a certain degree we did, but . . .” (#7). This view of advocates’ interests significantly hindered their public image because everyone involved in the Medicaid policy network agreed that the delivery of health care service under the Medicaid program prior to the reform was abysmal. As described in chapter 3, access to providers had always been limited, waiting times were unacceptably long, and the quality of care under the circumstances of constrained access has always been questionable. Thus maintaining the status quo was not perceived by anyone as a good idea. In comparing the status quo to reforms offered under MMC, for example, the following quotations are illustrative of participants’ views: Quite frankly, if I was an individual on Medicaid and I have a choice of sitting in the ER in the hospital clinic and being treated like cattle versus going to a private physician’s office, I don’t think it would be a really hard decision. (#66, hospital provider representative) One of the philosophical underpinnings of [MMC] was that these people ought to be treated the same. . . . Under the other [previous] system, if you’re a Medicaid person, then you’re treated as a Medicaid person. And frankly, I draw on a bit from personal experience. I had a child who was on Medicaid and who needed to see a specialist. So I went out for a nine o’clock appointment at UCONN Medical School. I was put in this big waiting room with a hundred people, all women and children. And by about 10:30 I went over and knocked on a window and said to the woman, “I have a 9:00 appointment.” And the woman said, “So does everyone else.” And I said, “Well that’s fine. I’ve waited an hour and a half. I’ll take my child to Boston or New Haven. I don’t need to sit here. I have a job and I cannot spend this kind of time.” And they told me, “Just a minute.” And in five minutes the doctor saw me. And basically these other women brought their lunch. They were there for the day, and they would be seen when it was convenient for them—no one had been seen by 10:30. It wasn’t like other people were being seen. And so when you hear doctors talk about people who don’t know enough to get there on time, there’s no rewards for getting there on time. In fact, they were smarter to show up late in the day and be seen last. It was a very dehumanizing experience, and that was very much my

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understanding of what they were trying to get away from with this reform. (#42, health plan representative)

Medicaid advocates made similar comments in our private interviews. For example, one advocate who works next to a hospitalbased pediatric clinic that predominantly receives public Medicaid funding said, “At our pediatric facilities we have residents and they’ve [Medicaid enrollees] been complaining that they don’t get a lot of continuity of care and we also have a problem with wait time. They wait a long time. Their biggest complaint is the wait time and the continuity. . . . There’s a lot of foreign residents with heavy accents and a lot of our patients have complained about they don’t really know what he is saying. They are intimidated by doctors” (#8). As mentioned above, all the advocates in the participatory process mentioned problems with the status quo in our interviews but never raised these problems in the public forum. Understanding these views provides more insight into why invoking the status quo as an unacceptable alternative in response to a criticism about the MMC approach had such a powerful silencing effect on the public discussion. Recall from chapter 4 when participants in the public forum raised concerns about equitable treatment, given the existence of separate Medicaid and commercial networks, and how the conversation abruptly ended when a representative from Blue Cross Blue Shield said that “there are more providers in our Medicaid network (under this new managed care reform) than had served the population under Medicaid’s previous FFS program” (#54). Once this claim—that this reform program is an improvement over the status quo—was brought to the fore, discussion about how well the program was achieving the mainstreaming goal ended. Clearly, Medicaid advocates did not want to defend the status quo because they also agreed it was problematic. But why did they not give voice to their more nuanced views? They could have discussed the limitations of the traditional Medicaid program, and this might have then made it easier for them to also discuss their concerns that HMOs under the reform were not living up to their promise of expanding access to private physicians. Although this sounds like a straightforward strategy at first blush, we show below how difficult public voice becomes, first, when advocates’ representation of the poor is questioned, and second, when public discussion can literally mean voicing concerns or criticisms about a longtime colleague and friend.

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SOCIAL TIES ACROSS THE CAMPS Although the strongest collaborative ties were between Medicaid advocates and providers, there were many other social ties across what, on the surface, might appear to be unlikely groups. The majority of participants had worked in the health policy domain for a long time—primarily on health care issues for underserved populations—and these individuals often moved between sectors and into different roles, from private to public, from for-profit to nonprofit, or from a position as an advocate at a social service agency to a position in state government. For example, one participant described how, at the initial planning stages of MMC in 1993, she was an advocate working for a nonprofit health service organization. She then worked for state government on a special health access project in 1994. Following this position, she worked for a commercial HMO with a Medicaid contract and was asked to sit on the MMCC as a health plan representative, from 1995 to 1996. Finally, at the time of our interview in 1997, she was the executive director of a nonprofit foundation. Although most participants did not have four different positions over a five-year period, about half of the individuals in the Medicaid policy network described having two to three different work positions, often moving from one sector to another and changing roles over the MMC planning and implementation stage. These shifts in employment result in social interactions among a sizable portion of individuals in a network. Other factors that increased interactions across competing groups were a number of joint ventures and special working groups created prior to and during MMC development. For example, HealthTrack was a private/public joint venture between DSS, the Hartford Foundation, and a number of health and social service organizations. The joint project created social interactions across sectors and, as discussed in the previous chapter, when the project was dismantled and the statewide Children’s Health Project created in its place, individuals took various positions within the Medicaid policy network but maintained these social ties. One person involved in the initial design and evaluation of HealthTrack, for example, went on to run a Medicaid outreach program for a commercial HMO. Another actor involved with HealthTrack became the executive director of CCHP and the CHC. Although the former individual is labeled a health plan representative and the

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latter is labeled an advocate in our effort to describe the actors in Medicaid network, these labels are stagnant and mask the richness of movement between roles in the network and the social interactions that emerge. Social interaction between members in the network shapes their understanding of Medicaid policy issues and problems. For example, when asked about the Children’s Health Project, the health plan representative felt strongly that this was not a good use of the state’s resources because the HMOs were already contractually required to provide outreach services. Indeed, that was her role in working for one of the commercial HMOs. However, she was quick to follow up her critical remarks with a qualification that she knows person X from the Children’s Health Project because they worked on HealthTrack together: “[I] trust her judgment and know she is trying to do what is best for the Medicaid enrollee” (#34). Her remarks in our interview made it clear that although she is critical of the Children’s Health Project and the monitoring role they play, it is unlikely she would raise this concern in a public forum because she would be criticizing a former and current colleague. Indeed, many people in our interviews mentioned friends working in organizations they might have just criticized. Sometimes they would mention friends as a way to say, “I know they mean well” or “I disagree, but trust their judgment.” One advocate working for a social service clinic said, referring to interviewee subject #46, who worked for a commercial HMO, “I have a friend [who works for] Blue Care and she does the HealthReach piece and she’s hearing a lot of the same things from patients. Brigita—I can get you her name and number—she would be a real interesting person to talk to, because she makes home visits to the houses, and really knows what’s going on.6 I heard from her that they [BCBS] do not help HealthReach. They totally knocked it down to three people that go to the home. She is one of the remaining ones and she’s very, very good” (#8). Notice how the advocate shapes her opinion about how well a commercial HMO is providing outreach to Medicaid clients based on information from her colleague in the network. Although she was critical of BCBS’s outreach efforts, she never raised this issue in public discussions in which she participated. Perhaps because she thought highly of her friend’s efforts and did not want her comments to be misinterpreted as a criticism of her friend. Our interview data suggest that when individuals had concerns, a primary strategy was to discuss the issue privately with friends in the network rather than risk raising the issue in the public forum

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and offending a friend. The issue of commercial HMOs expanding access to mainstream providers is a good example of this strategy in action. Although commercial HMOs were new players, many of the individuals representing the participating HMOs were longstanding members of the state’s Medicaid policy network. Among the thirteen health plan representatives from commercial HMOs participating in the public forums, six had extensive prior experience in the Medicaid policy network: two came from CHCs, two from nonprofit health and social service organizations, and the remaining two from the HealthTrack project. Logically, commercial HMOs hired people with Medicaid experience to run their Medicaid product. One result of hiring within the Medicaid policy network, however, was that criticizing commercial HMOs often meant a participant might literally criticize a previous colleague, and few people want to offend their friends in a public forum. When many participants discussed concerns that mainstream access was not being realized as promised under MMC, those with social ties to these individuals were quick to qualify the object of their concern as resting with the state, for lack of oversight or accountability, or with the HMOs, for lack of institutional supports to increase incentives for providers or to do more extensive outreach. Many clarified that it was systemic barriers that resulted in lack of access, and not the fault of individuals working for these organizations. Similarly, many Medicaid advocates were critical of CHCs’ strategy pursued under MMC but rarely voiced their concerns or criticisms in public. We describe the public discussion and advocates’ concern about CHCs below to provide another illustration of the silencing power of social ties. Medicaid’s primary traditional provider, CHCs, decided to create their own HMO for two reasons. First, CHCs did not want to be beholden to commercial insurers’ notion of “appropriate utilization.” There was concern that they would be right back in the position of having to defend why enabling services, for example, are medically necessary. They wanted to collaborate together to create an HMO that would then compete with these commercial HMOs rather than work independently to secure contracts with HMOs. They reasoned that if CHCs refused to contract with commercial HMOs, then the CHC-HMO would have a significant competitive advantage. Ironically, to secure collaboration with each other, they opted for creating their own plan and competing with other HMOs. From CHCs’ perspective the move toward MMC forced them to compete.

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The question was not whether they would compete but whether they would compete with each other or collaborate and compete against other HMOs. The second reason the CHCs decided to created their own HMO was similar to the argument for making child guidance centers “essential” providers. The CHCs believed they could offer, based on their long experience in working with Medicaid recipients and their attachments and understanding of recipient communities, an important community-based alternative (that commercial HMOs could not offer) for Medicaid consumers. Despite these logical reasons, this strategy became politically contentious because in the process of creating their own HMO, there was a rift among the CHCs and eventually they split and created two community-based HMOs: one for-profit and one nonprofit. The rift was fundamentally about whether nonprofit status was imperative to preserve the CHC mission. Those in favor of creating a nonprofit HMO argued that they couldn’t maintain their strong ties to the community and their unique selling points as a communitybased organization without the nonprofit status. Those in favor of the for-profit HMO focused on the advantage of raising capital and argued that with a larger reserve they would be more financially self-sufficient and ultimately better able to care for Medicaid enrollees, thus staying true to their original mission. The fact that CHCs could not resolve this issue among themselves and that some did, in fact, create a for-profit HMO created strong opinions among participants in the policy community about the appropriate role of CHCs under MMC. Besides creating their own HMOs, CHC-based plans also competed with commercial HMOs to become one of the default plans under MMC. Based on other states’ experiences, DSS believed that a sizable number of Medicaid recipients would never actually sign up for an HMO. Therefore, in anticipation of a high auto-enrollment rate, the state decided to designate two HMOs as “default plans” for which non-enrolled recipients would be automatically assigned. Many plans, including the CHC plans, submitted bids to be the designated default plan. Based on a competitive bid process, DSS awarded two commercial HMOs the default status. Not surprisingly, the two CHC-based plans were upset that they did not win the default contract. They believed that DSS was biased in favor of commercial HMOs and thought their experience with Medicaid patients should have given them a competitive advantage.

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Much to the CHCs’ dismay, when MMC was implemented, a high percentage of Medicaid recipients chose to join non-CHCbased plans. Because some CHCs were having financial difficulties, there was a public discussion as to whether CHC plans (and CHCs themselves) should be given any special provisions or financial assistance. One major point of disagreement had to do with the claim by CHC plans that Medicaid enrollees, who had chosen (or had been defaulted) into one of the commercial plans, continued to seek services at CHCs.7 At one MMCC meeting a CHC representative said that due to state marketing restrictions, they “had to make it their policy to see these patients once and direct them to the proper provider even though these enrollees wanted to receive services at their CHC” (December 8, 1995). The state’s marketing policy restricted plans from giving any information directly to enrollees. Instead, the plans were suppose to direct enrollees to the enrollment broker for “objective” information about all eleven HMOs. CHCs requested a lifting of some of these marketing restrictions so that they could better inform Medicaid recipients who ask for help at their CHCs. In response to their request a commercial health plan representative on the council said, “Voluntary enrollment numbers show that recipients are electing other plans rather than CHCs. It seems CHCs want privatization with special access. If they have access to the patients already, why do they need further marketing flexibility?” (#24) The CHC representative responded, “We don’t want anything special. The default rate is high and the lack of understanding about the system is evident when recipients are choosing to go to providers they have never seen before. . . . Also, people are choosing other plans because they are brand names—like BCBS—and the CHC plans have new names (other than the clinic name)” (#62, MMCC meeting, December 8, 1995). Shortly after this debate, DSS did lift the marketing restrictions requested by the CHC-created plans. For the remainder of our observation, the discussion focused on how to “protect CHCs” and “save our safety-net providers.” For example, one state legislator—an ardent supporter of CHCs as part of the “public health safety-net” and chair of the Public Health Subcommittee—continually raised concerns about CHCs in the MMCC meetings. The following exchange took place between legislators and bureaucrats at an MMCC meeting: State legislator (#16): Public health entities serve the working poor and uninsured in addition to the Medicaid clients they see.

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If we hurt them financially and they have to close, then it will cost the system elsewhere. DSS should look into grants to help them survive because today’s working poor or uninsured person may be tomorrow’s Medicaid recipient. State bureaucrat (#105): Aren’t these providers already getting money? Commercial insurers would be very unhappy if we gave extra money to certain providers. State legislator (#16): Do we save our public health infrastructure? State bureaucrat (#105): What we have now is a competitive system. State legislator (#75): [A bit later in the meeting.] The state is putting $10 million a year into community providers. If they go under there will be problems. State bureaucrat (#105): DSS cannot be financially responsible for systems beyond Medicaid. (February 2, 1996).

Although Medicaid advocates had long been proponents of CHCs and had fought for increases in CHC funding for their clients, they were silent throughout this public debate. Even nine months later, when a CHC did abruptly close, there was a short and closed interchange between a state legislator and a DSS bureaucrat at a council meeting: State legislator (#6): Have you analyzed how the CHCs are doing? Medicaid represents 23 percent of membership for CHCs. . . . We spend $4 million a year for the uninsured. Are they using this money to subsidize MMC? I have a concern that CHCs are going to go down the drain because of managed care. State bureaucrat (#9): DSS will be looking at this. We have had some discussions with CHCs. (November 15, 1996)

Not surprisingly, commercial HMOs and CHC-HMOs held very different views about the role of CHCs under MMC and whether the state set up a fair game of competition: FQHCs have obligations at the federal certification level to provide a wider range of support services. In addition to taking care of the Medicaid managed care population, they care for the uninsured and we need to offset the costs of that somehow. We don’t turn away those poorly behaving, high-cost individuals that other

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providers do. They [commercial HMOs] get to cream the population and send the rest our way, so no, I don’t think it is a fair game of competition. (#24, CHC representative) I think federally qualified health centers have gotten all the exceptions to the rule. Now whether that should be or shouldn’t, . . . it’s clearly not a level playing field regarding that. . . . The other thing I object to is [not] living by your business decisions. I think community health centers put all their eggs in a couple of baskets and when they didn’t win certain things, they wanted it both ways. And that I object to. (#32, health plan representative)

Although these two actors had very strong opinions that lodged them in one camp or the other, most participants, including Medicaid advocates, had more nuanced views about the health plan selection process and expressed an understanding of multiple sides of the debate. For example, although many Medicaid advocates thought commercial HMOs had favorable treatment due to their early access to DSS and resulting default status, they also did not believe that DSS should grant CHC plans special contracting provisions to solve these financial pressures: You’ve got community health centers competing against the proprietary sector, and it’s a whole new ball game. I would not say it’s a level playing field. Community health centers were the leading provider of health services to the Medicaid population, as well as the uninsured, and I think there’s a real concern that they are not going to be able to survive. . . . [But] we don’t want to necessarily bail them out. It was a good decision [to create their own HMO]. We just need to give them more time. (#6, advocate) I think that the community health center plans are different, for lots of obvious reasons. There are no other health plans that I know of in Connecticut besides HealthRight and CHN [Community Health Network] that have served the poor or the uninsured or cared to do so in the past. I think that there has not been acknowledgment of that commitment and that role. . . . Should DSS treat them any differently? I don’t think so. But should public health providers be treated differently? Probably, and generally my answer would be yes, but not specifically by [Medicaid], but by the whole state. I think there needs to be a careful examination of the role of the essential community and local public health providers and whether they will be able to continue to serve fragile populations

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and the uninsured as a result of this transition. But again, I don’t think that should be an effort by the DSS [under the Medicaid program]. (#15, advocate)

Although Medicaid advocates supported CHCs decision to create their own HMO, most advocates believed after the implementation of MMC that CHCs needed to live by that decision. Many mentioned that specifically because CHCs decided to create their own HMO, they should now be treated the same way other HMOs are treated. Part of the reason many participants believed CHCs should be held accountable for their decision had to do with the fact that CHCs created not one but two HMOs. The fact that CHCs could not agree among themselves about how to create an HMO did not bode well for their public image. DSS representatives were particularly angry that CHCs created two HMOs because they had given the state’s CHC association (the Connecticut Primary Care Association) a grant to help them create a CHC-based HMO. When CHCs started running into financial difficulties, DSS was not sympathetic because it believed CHCs had acted out of political motivations, had created their own problems, and now wanted the state to bail them out: What we wound up doing is we gave a grant to the Primary Care Association to form an FQHC [plan]. And the intent was that there was going to be an FQHC-based plan. Come to find out, the point where we issued the RFPs there were two. Which was just the politics internal to that organization. So the problems that they both experienced is the fact that they’re both competing, not only with the commercial plans, but they’re competing with each other. Anybody could predict that was going to happen. (#97, DSS representative)

Given the DSS grant proposal to help CHCs create an HMO, it is not surprising that DSS was angry. However, many Medicaid advocates who were typically supportive of CHCs also believed that CHCs were at least partly to blame for their difficult financial situation: Well, they split themselves up. No, I think they’re having a hard time right now, even though CHN comes in second and HealthRight comes in third. Still, in order to maintain financial viability, it’s a real iffy thing right now for them. They’ve put themselves in a scary situation, I think. (#16, advocate)

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I think that there are a few [CHCs], or one in particular [the one that closed], that is suffering at the hands of managed care and probably because of lack of foresight and lack of planning. So it’s been very problematic. It has really consumed an awful lot of our energy specifically because of, you know, the concerns that we had about the agencies that are already in place and serving this population and trying to maintain the quality of care, the level of care and ensure that everyone has access. (#7)

Although the majority of Medicaid advocates held nuanced views about CHCs’ role in MMC, they remained silent on this issue in the public forum. In the MMCC Public Health Subcommittee they advocated doing something to make sure CHCs were available for the non-Medicaid poor, but they never raised the issue in public discussion at the MMCC meetings or tried to clarify their view that Medicaid should not be responsible for bailing CHCs out of trouble. Advocates’ silence around the issue of CHCs is related to their silence around HMOs expanding access to mainstream physicians. Both issues were politically charged so that the public discussion that did occur reflected sharp divisions and tended to have the effect of dividing participants into two camps: you were either for MMC reform and commercial HMOs participation or against MMC reform and for the status quo of relying on CHCs and other traditional Medicaid providers. One in four participants mentioned (unprompted) that they thought issues related to the HMO selection process were highly politicized: “I think that they got caught up in a lot of cross fire around politics which is not a good way to do business” (#13, Medicaid advocate). Indeed, in our private interviews Medicaid advocates often threw up their hands and said, “Its all politics” when the issue of HMOs and CHCs came up. Because Medicaid advocates were already perceived as having uniform views aligned with Medicaid provider interests, they worried that even a nuanced advocacy to help CHCs outside of the Medicaid program would still put them further into the status quo camp. Thus similar to mainstream access, Medicaid advocates had difficulty voicing concerns about CHCs in part because they lost their legitimacy to speak as independent advocates for the poor. Instead, they were viewed as aligned with particular invested interests. However, they also had difficulty criticizing CHCs for the same reason they had difficulty mentioning the limitations of Medicaid providers under the status quo. Because CHCs and Medicaid

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advocates had collaborated on various initiatives for so many years, most advocates had longstanding professional ties with CHC representatives, and public criticism of CHCs (or even perhaps a more mild discussion about holding them accountable) would have been perceived as publicly criticizing their longtime friend. Rather than raising a concern about CHCs in the public forum, participants seemed to prefer private discussions with colleagues. For example, when we asked an advocate their opinion about CHCs developing their own HMOs, this participant mentioned a private conversation with a CHC representative: I don’t know. I asked [the director of a CHC] that. Why did they go down that road? He said that they would not have been a player if they had not gone down that road. So I think that they saw it as a need to survive. [Q: What do you think? Do you think it was a good decision?] I think the concept was right. But they need to understand that it’s the big league that they’re playing in now. Maybe they should have contracted [with all HMOs] like the school-based health clinics. But I understand why they did it. (#19)

Although this participant disagreed with the CHC’s strategy, she understood through private conversations why they did it. And, because they were longstanding professional friends, she would never dream of raising this concern in a public forum. Just as other studies have found in relatively small interconnected networks, strong social ties can inhibit what people feel comfortable saying in a public forum.8

CONCLUSION Medicaid advocates in our study wanted to enter the public forum as “objective observers” speaking on behalf of the poor. When asked, advocates described their role in the public forums as providing a voice for the poor, which, they mentioned, was otherwise not heard. “I try to remind people that these are public dollars for services for people who need publicly funded social services,” one advocate said, “and what that also means, from my perspective, is that these are people who historically have not been able to have

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the resources to advocate on their own behalf. And so we have to be careful” (#1). Yet this chapter illustrates how the capacity of nonprofit service organizations to represent the poor can be compromised when the rules of the game change and nonprofit providers are asked to compete. We find that under a change in the contracting regime, from collaboration to competition, nonprofit service providers increase political activity to secure a favorable role under the new regime, but at the same time they lose their ability to act as representatives of the poor. In addition, even Medicaid advocates, who do not work for nonprofit service organizations and do not depend on Medicaid funds, can lose legitimacy as advocates for the poor. In our Medicaid case, increased political activity, because it was perceived by others in the network to reflect significant political influence on policies many disagreed with and strong social ties to a politicized group, came with deliberative costs. The main cost was that Medicaid advocates could not legitimately criticize commercial HMOs without being perceived by many in the network as partisan and political and as ultimately wanting to maintain the status quo. Ironically, although social interactions across competing groups in the network helped to improve opinions of fellow participants and the understanding of issues, these social ties also dampened public voice. Because social interactions led to apprehensions about offending colleagues in a public forum, participants appeared less likely to raise concerns—especially around the issue of expanded access because it most specifically related to the performance of various actors—when they had strong social ties in the network. As a result, the potential benefits of greater tolerance for opposing views and understanding of multiple points of view, which were evident in our private interviews, were not realized in the public forum. Most important, the voice for the poor was lost on the key issue of expanding mainstream access that was repeatedly stated as a central goal of MMC reform. Only objective, independent representatives of the poor could have truly fought for equal access, and they— really—were nowhere to be found.

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Conclusion

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6 Medicaid Reform and Advisory Boards WHO WILL ADVOCATE FOR POOR PEOPLE’S HEALTH?

The primary goals of this book are to highlight the problem of public silence in deliberations over public policy and to offer an explanation of why it occurs. Specifically, we are concerned with deliberations among members of state advisory boards. These boards are ubiquitous in American politics, but we know very little about the public conversations that might emerge from them. When they are used to inform health and social policy, these advisory boards are often composed of representatives from the vast network of nonprofit agencies that provide services to and/or advocate on behalf of the poor. Evaluating the substance of deliberations within these boards provides us with an opportunity to better understand the degree to which these agencies can offer an avenue for representation of otherwise disenfranchised groups. Let us begin this concluding chapter, then, by reviewing briefly why the problem of public silence is important and summarizing our explanation of why it happened. After that, we will conclude by offering a few thoughts on what can be done. THE PROBLEM OF PUBLIC SILENCE To appreciate why public silence is problematic we have to remember why participatory processes are important. In chapter 1 we identify five benefits that could emerge from public discussion: (1) a greater understanding and more tolerance for opposing views, (2) a public-spirited way of thinking about social problems (as opposed to a self-interested view), (3) increased clarification and refinement of participants’ positions on issues, (4) learning about the

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consequences of implemented policies and the reasons for past failures, and (5) decisions emerging from an open and inclusive deliberative process, where all individuals can freely voice their concerns, are more democratically legitimate. These are the main reasons for encouraging public discussion, but recognizing the importance of public discourse does not suggest that all voices should have equal say over matters of actual policymaking, nor does the voicing of concerns guarantee that these benefits will emerge. We can be sure, however, that none of these benefits will emerge under silence. Even more troubling than the loss of potential benefits (opportunity costs, if you will) are the problems that public silence can produce. First, as we discussed in chapters 4 and 5, most participants held nuanced views about managed care and the role of HMOs, CHCs, and other Medicaid providers. Yet during the few public conversations that did occur on these various issues, the voices that emerged represented more extreme perspectives. Some suggested that recipients’ access had expanded to be equal to mainstream care; others suggested that recipients’ access had not expanded at all. Without an open public discussion of the mainstreaming issue, the nuanced positions we heard during our private conversations were lost, as was the opportunity to identify common areas of concern and compromise. Second, silence allowed participants to make assumptions that are often wrong, about other participants’ motives and interests. For example, in our case study, HMO and DSS representatives wrongly assumed that Medicaid advocates just wanted to maintain the status quo, and some Medicaid providers and advocates wrongly assumed that HMO representatives did not care about improving access to mainstream providers for Medicaid recipients. Third, silence can preclude the opportunity for participants to learn more about a problem because even if discussing an issue does not lead to a solution or policy change, it often leads to generating more data to understand a problem. In our study, silence about equal access precluded the opportunity to at least collect data on the issue, and, consequently, participants were left just as ignorant two years after implementation as they had been during the design phase about how well managed care was actually able to expand access to mainstream medical care for poor Medicaid recipients.1 If they would have collected data on HMO policies about provider participation, they would have learned that not all HMOs acted the same. For example, one HMO let as many physicians sign up

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for as few Medicaid patients as she or he wanted, whereas another HMO mandated under the physician contracts that if their patient panels were not full, then the physician had to accept all HMO members equally—whether Medicaid or private paying. Had participants known these facts about the issue, they might have suggested rewarding the HMOs that employed more “equal” physician participation policies, just as they suggested rewarding HMOs that do better treating asthma. Finally, silence on topics participants care about can create a cynical view regarding the entire deliberative process. For example, those who cared about mainstream access yet did not discuss it publicly tended to have a more cynical view about the advisory board and state Medicaid policy in general. These people believed that Medicaid had always supported a two-tiered system of care and that MMC was yet another facade masking the reality of inferior care for poor families. Unfortunately, it is difficult to imagine how Connecticut, or any other state, can move away from a two-tiered system if we cannot first devote time and energy to discussing how we might reach the goal. In sum, we want to be clear that public discussion about topics of concern does not guarantee any particular policy outcomes or social benefits. Benefits, however, are possible. Moreover, it is important to take heed that public silence can, and in Connecticut did, create problems. Deliberation is not sufficient to change policy, but silence rarely serves to advance the interests of the poor.

EXPLAINING PUBLIC SILENCE Because so many books address political inequality and the suppression of political voice, it is tempting to simply conclude that public silence occurred in this case, and perhaps in most deliberations, due to political inequality among participants. Indeed, the exclusion of Medicaid advocates and providers from the initial decision-making process naturally leads one to question whether advocates did not talk about equal access because they felt overpowered by other participants in the public forum. As we describe in chapter 5, however, Medicaid providers and advocates were hardly docile participants with no political power. In line with a wealth of literature on the political activity of nonprofits, we found that nonprofit social service providers and

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nonprofit advocacy organizations had long-held ties with state government agencies and elected officials. When they were excluded from the initial discussions with DSS representatives, they ramped up their political advocacy and accomplished some major wins: creation of an open, inclusive advisory board; creation of an oversight body with appropriated state resources; and creation of policies to protect Medicaid recipients’ access to specific Medicaid providers. These were not minor concessions on the part of the state but major wins that DSS and HMO representatives advised against. Indeed, DSS and HMO representatives resented the granting of protections to some providers and not others, and the extra time devoted to meeting the data collection demands of the oversight body. Most important, they interpreted these wins as signaling significant political power by Medicaid providers and advocates. Medicaid providers and advocates also discussed the importance of their political connections to secure these wins. Given the acknowledged strength of these representatives of the poor, the simple political inequality story doesn’t work very well as a key explanation for public silence. Indeed, when we analyzed the public discussions that did occur, we found Medicaid advocates and providers to be the able representatives that deliberative theorists call for. Because they had been part of the Medicaid policy network for a long time, most advocates and provider representatives had a very good grasp of Medicaid policy issues. Therefore, even though they did not have an alternative solution for controlling Medicaid costs when DSS discussed moving to a competitive bid process, they asked detailed questions and wanted to be involved in the decision-making process. Even on highly technical issues, such as Medicaid reimbursement formulas for HMOs and measuring health care outcomes to determine appropriate quality of care, advocates did not defer to experts but asked pointed questions and made challenging remarks. Again, the political inequality argument did not hold up to the discussion we observed. Yet another alternative explanation is that the institutional factors related to the topic of equal access—political feasibility, lack of data, and lack of solution—stymied public discussion. As described in chapter 4, we do find some support for this argument, but when we compare the influence of these factors to the topics that were discussed, their explanatory power comes up short. For example, it is likely that the political and budgetary climate dampened the hopes of many participants that significant progress could be made on attaining mainstream access for Medicaid recipients. But many were

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equally pessimistic that the quality of care provided could also be improved under reduced funding, and yet they continued—despite their privately expressed fears—to fight publicly for the importance of improving the quality of care provided to Medicaid recipients. Moreover, the lack of an alternative solution might have made it more difficult to discuss mainstream access, but why then were participants eager to keep a sustained conversation about costs on the public agenda when there were no easy solutions about how to increase funding or change the reimbursement methodology? Moreover, our private interviews revealed that most participants believed that reliance on HMOs through the Medicaid managed care reform was the best hope for expanding access to mainstream providers. So why didn’t participants fight for this to happen in the way they envisioned it would? Finally, although it is clear that the availability of cost data enabled participants to have a focused and sustained discussion about this topic, it is unclear why participants did not raise public discussion about the importance of collecting of data for the purpose of tracking access to mainstream providers. There were no data on health care outcomes for Medicaid recipients when the reform started. Yet in stark contrast to the mainstreaming goal, participants devoted countless hours to discussing the importance of data collection and what data were important to collect. Although the combination of all three factors contributed to a limited public discussion around the goal of improving access to mainstream medical care, we show in chapter 5 how understanding the Medicaid policy network, and how Medicaid managed care reform changed the interests and participants in that network, provides the key additional explanatory pieces to the public silence puzzle. On the one hand, our findings concur with studies by Chaves, Galaskiewicz, and Stephens (2004) and Berry and Arons (2003) suggesting that nonprofits with significant government funding have high levels of political activity. Yet by analyzing the content of public discussion and advocacy, we are able to shed light on the “black box” of nonprofit political activity. An important contribution of our study is realizing that nonprofits may increase political activity due to a change in government funding or a change in government policy, but they may also suppress political voice. In our case the Medicaid policy network prior to MMC reform is similar to that described by Berry and Arons (2003): a close-knit community of representatives from nonprofit health and social service organizations and nonprofit advocacy organizations working

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with state agency heads and elected officials on Medicaid policy. As described above, nonprofit representatives operating under Medicaid had significant interactions with state bureaucrats and elected officials and were highly involved in Medicaid policy. MMC reform changed this close-knit network by bringing in new participants from the HMO industry and changing the rules of the game from encouraging collaboration among nonprofit service providers and advocates to improve continuity of care to encouraging competition among providers to create customer-based incentives to improve access and the quality of care provided. Under this competitive contracting regime, Medicaid providers were now expected to act as self-interested organizations contracting or competing with HMOs to capture the Medicaid market. Clearly, this new contracting regime did not assume that Medicaid providers would act as representatives of poor Medicaid clients. Medicaid advocates, from nonprofit advocacy organizations or foundations, however, were still expected to play that role. Indeed, this was their official status in the deliberative forum and how they described their role in our private interviews. Yet given their close collaborative ties with Medicaid providers, as well as their advocacy efforts to protect access to some Medicaid providers, many other participants questioned advocates’ ability to truly represent the interests of Medicaid recipients. This distrust, and their close association with Medicaid providers, made it difficult for them to criticize HMO actions without others in the deliberation simply discounting their view as partisan and biased in favor of the status quo. In this sense, their assessment of HMO performance was not considered legitimate. Ironically, the close collaboration also made it difficult for advocates to criticize the actions of Medicaid providers, because as several other studies have found, it is difficult to publicly criticize colleagues and friends. Our study shows how a policy reform can change nonprofit representatives’ ability to adequately represent the poor. In particular, a contracting regime change can delegitimize nonprofit advocacy either by creating a direct conflict of interest or by creating a perceived conflict of interest due to previous established ties.

WHAT CAN WE DO TO IMPROVE THE PARTICIPATORY PROCESS? What we do to improve the participatory process depends on the reason for the problem. As noted, there are two major reasons for

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public silence. First, a widespread belief among many participants that the political climate and the problem itself (due to lack of data and policy solutions) was infeasible, leading to an informal assessment among participants that discussion of the topic was not worth the effort. Second, conflict of interest and social interactions within the policy network after MMC delegitimized nonprofit advocacy for the poor and made discussion of the mainstreaming topic difficult. Below we propose possible responses to each of these barriers. Planners of participatory processes should think carefully about not only who to include but what topics are important to put—and keep—on the agenda for public discussion. Directly following from our case study, we offer two specific suggestions for identifying topics that might fall prey to public silence. First, determine if policy reforms have changed “the rules of the game,” and if so, consider whether some public discussions of policy goals make some participants more vulnerable under these new rules. Second, determine if some policy goals suffer from multiple technical and political feasibility problems making public conversation more difficult. Once topics are identified as vulnerable to public silence, planners can preset the agenda to make sure that these topics have a place on the public agenda over time, and planners can identify a neutral mediator to help facilitate discussion around these more difficult topics. We acknowledge that this preplanning comes with costs, but we argue that the costs associated with public silence are far greater and therefore point to the importance of intentional inclusion. How to Encourage Deliberation over the Possible? A deliberative process could set up two mechanisms to incorporate discussion of goals viewed to be infeasible. First, deliberative bodies must provide space on the agenda to discuss all program goals. That is, discussion of goals, even those issues with no immediate solutions, must be scheduled into the meetings or immediate concerns that are viewed to be politically feasible will always take precedence. Such scheduled discussion could entail as little as five minutes at the beginning and end of each meeting. Discussing seemingly impossible goals at the beginning and end of a public forum may help participants to see connections between immediate actionable steps and larger goals that seem unreachable. Discussion may reveal to the group whether and where there is consensus and disagreement, and may reveal if something can be done, such as collecting data to better understand the goal or concern.

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The second mechanism that needs to be put in place—and this is crucial—is to provide a purpose for why the group should discuss a goal perceived to be infeasible. Because participants on advisory boards, and in policy networks in general, work hard to make changes, they do not want to be dismissed as politically naïve. As a result they often are reluctant to discuss issues that seem politically infeasible in the short term. Especially because of this understandable inclination, deliberative bodies should be encouraged to think of themselves as laying the groundwork for when windows of opportunity emerge (Kingdon 1984). Such encouragement might allow participants to think about the broader political climate as dynamic in the long term. In this light, discussions that seem fruitless now can be viewed as worthwhile for changing public discourse for some future date. Of course, it is complete conjecture as to whether deliberative bodies would buy this set of rationales as sufficient reason to engage in public discussion about concerns which they believe to be unacceptable in the current political climate. Yet based on our interviews, in which participants wanted to discuss these suppressed issues, there may be a potential untapped willingness to engage in public discussion around difficult issues as long as the “rules of the public discussion” were considered safe. Who Should Represent the Poor? We do not believe that our study provides evidence that nonprofit service organizations, and the advocates with whom they work, are incapable of representing the poor. We document in the opening chapter of this book the myriad problems associated with representing the poor in the American political system and in specific policy processes. With growing economic inequality and declining faith in the electoral system, the problem of political disenfranchisement among our poorest and most vulnerable citizens is becoming worse, not better. Under these circumstances, we should pursue a host of reforms designed to expand political participation and improve representation, such as grassroots mobilization, campaign finance reform, and voting rules. But these efforts should supplement, not replace, the representative role of nonprofit organizations. Nonprofits represent a central component of our modern political economy. In providing a vast array of health and social services, they obtain a unique and crucially needed perspective on the lived experiences of persons in underserved and otherwise politically

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disenfranchised communities. Since these organizations often have rules for community participation, and states have numerous participatory decision-making processes in place, nonprofit organizations already play a significant role in advocating on behalf of the poor at the local and state levels. As Berry and Arons (2003, 114) state, “Citizen participation is really non-profit participation” at the state and local level. Surely, given existing levels of political inequality, we would not want to take this voice away. On the other hand, we’ve identified a problem with using nonprofits to represent the poor when resource dependency is high, when strong social ties are embedded in emerging conflicts of interest, and when they are operating within a competitive contracting regime. As we explain in chapter 5, nonprofit service providers increase political activity under such a regime, but they lose their ability to act as representatives of the poor. Even Medicaid advocates, who do not work for nonprofit service organizations and do not depend on Medicaid funds, can lose their legitimacy as advocates for the poor under a contracting regime because of their close ties with these nonprofit providers. This finding is significant because although other studies examine the implications of market competition for the organizational performance of nonprofit healthcare organizations (Schlesinger and Gray 2006; Malani, Philpson, and David 2003), to our knowledge we are the first to identify the implications of market competition for the ability of nonprofits to serve as representatives of the poor. Overcoming the Limitations of Nonprofit Representation If a topic is not on the table either because there is an actual or perceived conflict of interest or because the social relationships among members of the nonprofit community inhibit consideration of certain topics, presetting the agenda to discuss these difficult topics is not a sufficient response to the problem. Eliminating nonprofit organizations that have an organizational stake in the outcome of policy debates, or with whom other members of the network have personal relationships, is a practical impossibility and does nothing to expand the agenda or foster greater deliberation. Increasing direct participation by citizens for whom the policy is designed to help is always desirable but not very realistic. Due to numerous resource constraints that make increased political participation among the poor more challenging, increasing participation in public forums is similarly challenging. Moreover, several

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studies have found that citizens are often intimidated by advisory board processes and are too willing to defer to “experts.” More realistic, and ultimately more effective, is to include representatives of community-based organizations without a direct stake or interest in the policy under consideration. For example, in the case of Medicaid or health policy reform, a representative who works on economic development might be best positioned to bring the nonconflicted voice of the community to the public forum. This would combine the strengths of direct participation with the skills needed by able representatives to challenge expert authority. At the same time, however, the same invested stakeholders should still be involved in the participatory process. Although we focused on the problem of public silence, it is important to remember that Medicaid advocates from nonprofit, community-based organizations did not hesitate to challenge technically complex state decisions with regard to quality monitoring and cost containment. They were the able representatives of the poor that we would want them to be. Yet they cannot be expected to play this role for all topics, especially under a contracting regime change in which nonprofit providers were expected to compete directly with other participants in the public forum. The effect of competition on social dynamics and interests within the participatory process should be recognized, and the inclusion of representatives, without a direct competitive stake, should be expanded. In conclusion, we want to emphasize that public discussion, even of the full range of issues, does not guarantee that the potential benefits of deliberation—more tolerance and understanding and more legitimate policy outcomes—will emerge. Yet it is likely that none of the benefits associated with deliberation and some of the problems of public silence will emerge if we never have the courage to engage in a more open public dialogue about topics of great concern. Indeed, it is difficult to imagine how we can move closer to reaching a public goal if we cannot talk about it in a public forum.

Notes

Chapter 1. The Problem and Puzzle of Public Silence 1. To maintain confidentiality, we do not use her real name. 2. Although the more accurate term used today is “managed care organization,” we use “HMO” because this is the term used most commonly in the popular press and by the public. Because this chapter, and the book, is not primarily about managed care or managed care organizations, we use the term that has the most ready, accessible meaning to a more general audience. 3. Eliasoph used this quotation to make her point that open, political talk among common citizens is important. 4. Some argue further that because the deliberation can be a creative process—with participants brainstorming and generating new ideas—the process may be able to overcome (or at least lessen) the impact of limited knowledge on decision making (Disch 1996; Fearon 1998; Gambetta 1998). For example, the process of discussion may reveal that there is no compromise on the known set of policy alternatives and therefore creates an incentive to think of new solutions. Thus the end result is not only new solutions but also consensus over the policy decision. 5. See the Kaiser Commission on Medicaid and the Uninsured website at http://www.kff.org/medicaid. 6. For details on these recent state Medicaid reforms, see the National Conference of State Legislatures website, http://www.ncsl.org/programs/ health/ (1115waivers.htm) (accessed June 27, 2006). 7. Actually, Medicaid managed care demonstration projects started in a number of states in the mid-1980s. They were primarily of a different form, called primary care case management, but they led the way for the flurry of waiver activity in the early 1990s. For more detail on these early waivers in the 1980s and the increased activity in the 1990s, see Hurley, Freund, and Paul 1993; Davidson and Somers 1998; and Thompson and DiIulio 1998. 8. Although not central to our purpose here, which is to understand how Connecticut’s advisory board is similar to those set up in other states, it is interesting to note that the federal government’s Department of Health and Human Services also created its own Medicaid Commission in 2005 to consider short- and long-run Medicaid reforms. There is a

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strong operating consensus among commission members and the National Governors Association that “from a state budget perspective Medicaid is unsustainable. . . . For Medicaid to be sustainable in the long-run, broader program and health care reforms must be considered.” 9. One respondent refused to be interviewed on tape. In this case, the interviewer took detailed notes during and immediately following the interview. 10. In order to check for intercoder reliability, at least two people coded the same interview files separately. We then compared the codes to check for reliability and discussed each of the discrepancies. Generally, our intercoder reliability scores have been acceptable, based on the 80 percent agreement guideline suggested by the General Accounting Office for content analysis (GAO 2000). 11. Due to time constraints, four interviewees were unable to complete the entire interview protocol. Hence, we have a total of ninety-six fully completed interviews. The completed interview response rate is 93 percent. 12. This is not to say that discussion about national health insurance would be wrong or undesirable but, rather, that it seems unfair to expect participants—given the context of the public meetings—to discuss the topic. More to the point of our study, the question of why participants were silent on this issue is misplaced or, at the very least, uninteresting when there is no reason one should have expected them to discuss it.

Chapter 2. Explanations for Public Silence 1. Although Hays (2001) shows how there is a strong and consistent network of government, nonprofit, and public organizations involved in public policy discussions about programs for the poor at the federal level. 2. This is also a common “resource dependency” argument expressed in the organizational theory literature. 3. They measure the following type of political activity for the congregational study: “(1) whether people at worship services have been told, within the past 12 months, of opportunities for political activity; (2) whether voter guides have ever been distributed to people through the congregation; (3) whether the congregation had a group, meeting, class, or event, within the past 12 months, to organize or participate in a demonstration or march to support or oppose a public issue or policy, (4) or register people to vote, (5) to discuss politics, or (6) to organize or participate in efforts to lobby elected officials of any sort; and whether within the past 12 months, (7) an elected official or (8) anyone running for office spoke to the congregation. All these variables were dichotomously coded” (Chavez, Galaskiewicz, Stephens 2004, 302). For the nonprofit twin cities study, they measure two variables: (1) “had engaged in lobbying efforts on your own” and (2) “scale ranging from 0–3, indicating whether organizations had launched major public or

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community relations efforts aimed at politicians, government agencies, or legislative bodies” (305). 4. There are important definitional and conceptual differences between these terms (see McGregor 2004). For ease of language we sometimes use the term “policy community” in place of “policy network”; however, we are always conceptually referring to a policy network using the definition provided above, which we believe best describes the Medicaid policy domain. 5. Walker (1991) also made this point. 6. See also a special issue on the “Politics of Numbers” in the Journal of Health Politics, Policy and Law 19, no. 1 (Spring 1994): 7–26.

Chapter 3. Medicaid’s Persistent and Conflicting Goals 1. Numerous articles have been written about Medicaid’s failings—too numerous to mention here. A good place to start, however, is an edited volume reviewing the program by Thompson and DiIulio (1998). Some may argue that Medicaid’s failings really have to do more broadly with the lack of national health insurance in the U.S. Again, volumes have been written on this topic. Some recent analyses that offer superb arguments to illuminate this aspect of U.S. exceptionalism include: Quadagno (2005); Derickson (2005); Mayes (2004); Hacker (2002); and Klein (2003). 2. This term, “dual-track health care,” was coined by Rosenblatt (1975). 3. Although Medicaid’s reality and image cannot so clearly be characterized as welfare medicine today, it is a legacy that remains with the program (Grogan and Patashnik 2003a, 2003b). 4. Of course, there is a history prior to this, but this time marks the first big push to create public facilities for the poor. 5. This section relies heavily on Grogan (2006). 6. See Hurley v. Eddingfield, 156 Ind. 416, 59 N.E. 1058 (1901). 7. Actually, many older people still remained in the county hospital since their age-related disability often caused impoverishment (or what later became called “medical indigency”). Private hospitals also had public wards, but there as well the poor were clearly and purposefully segregated. 8. See Holstein and Cole (1996) for a discussion of how Small Business Administration and Federal Housing Administration construction loans encouraged the building of private for-profit nursing homes. 9. We do not mean to imply that these arguments explain the passage of Kerr–Mills and the downfall of Medicare in 1959 (for that, see note 1 above for references on the lack of national health insurance in the United States), but that these arguments do help explain why we ended up with these rather unusual expansionary provisions in a means-tested program. 10. This quotation is orginally from U.S. HEW 1967. 11. Stevens and Stevens’s (1974) historical account of Medicaid also concurs with this conclusion.

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12. This quote is orginally from U.S. HEW 1967. 13. This bizarre fractional percentage to determine eligibility is a testament to Medicaid’s complexity. 14. There were some exceptions to the SSI federal standards. Some states were allowed to set lower state-defined eligibility levels. 15. This section relies heavily on Grogan and Patashnik (2003b). 16. For a provocative argument that the political unpopularity of AFDC reflects racial coding, see Gilens 1999. AFDC notwithstanding, the political durability of means-tested programs more generally is a matter of debate among welfare state scholars and practitioners. For contrasting views, see Skocpol 1995, and Greenstein 1991. 17. The Medically Needy programs allow states to cover those who have large medical expenses relative to their incomes. The 300 percent rule allows states (that so chose) to cover those needing nursing home care whose income does not exceed 300 percent of the federally defined SSI level. 18. See also Davidson’s (1982) review of the literature. 19. Rosenblatt footnoted the following references on this point: DeVise 1969; Center for Analysis of Public Issues 1972; Report of the Mayor’s Task Force on Public Health Goals, Washington, DC (1969). 20. Though even at this time these studies also found other factors, such as administrative burdens (e.g., payment delays, cumbersome claim forms), demographic and ideological characteristics of physicians, physician perceptions of Medicaid recipients, and geographic location of physicians to Medicaid members, to be significant. 21. Watson (1995) obtained these data from the Physician Payment Review Commission, Annual Report to Congress (Washington, DC: GPO, 1994), 353. 22. Reisinger, Colby, and Schwartz (1994) calculate the total costs needed to bring Medicaid fees up to Medicare levels. Again, their estimate of $3.23 billion is viewed as difficult given the reality of state budgets. 23. A study by Baker and Royalty (2000) also supports this view that fees have little impact on participation rates. Unlike previous cross-sectional studies, they used panel data and found that although there is a significantly positive relationship between the Medicaid/private fee ratio and physician participation without state dummies in the model, when fixed effects are added the relationship is insignificant. Based on these findings, they suggest that states with relatively high fees have higher Medicaid physician participation rates than states with relatively low fees. However, using a fee increase as a policy tool to increase Medicaid physician participation within a state will be ineffective (or at least only minimally effective). 24. Fossett and Peterson (1989), as well as Mitchell (1991), also find residential segregation to be a significant factor in their analyses of physician participation. 25. Based on the residential segregation findings, Rowland and Salganicoff came to a similar policy conclusion: “Regardless of the increases in

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payments to physicians, administrative simplifications, and system reforms, individuals who now live in medically underserved remote rural areas and destitute pockets of inner cities are likely to continue to reside in such areas. They will continue to need clinics and hospital outpatient and emergency departments to meet their health care needs” (1994, 552). 26. Some would argue, however, that although targeting public facilities would maintain our dual system of health care, such an approach would expand access and thus make the system as a whole more equal than our current separate and unequal system of care (see Fossett, Peterson, and Ring 1989). 27. Although these authors analyze physician willingness to participate, it should be noted that Kletke et al. (1985) found that interview data are an unreliable measure of the extent of physician participation because physicians tend to overstate the proportion of Medicaid patients in their practices. 28. During the presidential race in 1992, the lack of health care security was a prominent issue. And after Bill Clinton’s election, for a moment, it appeared that national health insurance—the aspiration of liberal reformers since the 1940s—was an idea whose time finally had come. Of course, for political reasons too numerous and complex to explore here, Bill Clinton’s health care reform plan failed to become law. As a result, efforts to do something about the uninsured focused (as it did in the 1980s) on expanding Medicaid. 29. As noted above, this description is how Medicaid managed care should ideally work in theory. Of course, states and HMOs can lose money in a number of ways. For example, states that allow voluntary enrollment can lose money if HMOs realize favorable selection, whereas HMOs can lose money if they suffer from adverse risk selection. 30. In their view, giving more money to participating providers was not a good use of “extra” Medicaid funds. These findings are based on personal conversations with agency heads at the Department of Social Services in 1997.

Chapter 4. The Political and Policy Difficulties of Discussing Unequal Access 1. These were Hartford and New Haven Counties. 2. For confidentiality reasons, participants in the deliberations have different identification numbers from those given in the private interview. Therefore, if the same number appears for quotations in the public meeting and the private interview, the quotations do not represent the same person speaking but two different people. 3. Public Law 104-193.

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4. We discuss in chapter 5 how SBHCs gained “essential” provider status under Medicaid managed care, which means that all the HMOs were required to contract with SBHCs.

Chapter 5. Medicaid’s Policy Network and the Ties that Bind 1. To maintain confidentiality we hide the actual name of this program. 2. She was the litigation director at Legal Aid Society of Hartford, Connecticut. 3. Tennesee’s Medicaid-funded Tenncare program was an exception (see Watson 1995 for more details on this case). 4. The private foundation is the Hartford Foundation for Public Giving. 5. Although the central purpose of our study was to understand the factors that explain public discourse, we did not anticipate that the role of social networks would be a central explanation in our story. Because it was not our purpose and we did not anticipate this, we did not conduct a formal network analysis in our interviews (i.e., asking about social ties and attempting to determine the strength of ties). The data on social ties come organically from our interviews without us formally asking about social ties. The lack of a formal network analysis makes it difficult for us to present accurate information on the extent of social ties within the network. However, if there is a bias in our data it would be an undercount, suggesting that the effect of social ties would be even greater than we present here. The fact that social ties emerge as a significant factor on its own from our interview data, without us specifically asking about social ties, makes the emergence of this factor as a key part of our story even more powerful. 6. Her name has been changed to maintain confidentiality. 7. We will explain in more detail below what “default status” means. 8. See Mansbridge (1980) for an example of how social interactions in a small New England town made citizens reluctant to discuss certain topics in the public town hall meetings.

Chapter 6. Medicaid Reform and Advisory Boards 1. DDS did actually hire a consultant to do a small, simple audit of HMO provider lists (where they did in fact find problems), but this report was never discussed in the public forum.

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Index

access to health care providers inequality in, 4–5 private concerns regarding, 71–73 protected status for Medicaid providers, arguments for, 98–100 public silence regarding, 5 (see also public silence) See also mainstreaming Adams, E. K., 60 advisory boards/committees Medicaid Managed Care Council (see Medicaid Managed Care Council) reasons to study, 10–12 Advocacy Coalition Framework (ACF), 40 advocates for Medicaid clients. See Medicaid advocates AFDC. See Assistance for Families with Dependent Children agenda setting, 6, 36 aggregative model of democracy, 24–25 Aid to Dependent Children (ADC), 44 Aid to Dependent Families (ADF), 45 Aid to the Blind (AB), 45 almshouses, 43–44 American Political Science Association, 27 Arizona, 63 Arnstein, Sherry, 11 Arons, D. F., 29, 31–36, 125, 129 Assistance for Families with Dependent Children (AFDC), 53–54 Baker, L. C., 134n23 Balla, S. J., 11 Bay of Pigs, 9

BCBS. See Blue Cross Blue Shield of Connecticut Berry, J. M., 29, 31–36, 125, 129 Blue Cross Blue Shield (BCBS) of Connecticut, 69–71, 106, 108 budgetary climate/politics, 83–85, 124–25 Button, M., 29 Chaves, M., 32–36, 125 CHC. See Children’s Health Council CHCs. See community health centers Children’s Health Council (CHC), 5, 17, 102 citizen participation forms of in democracy, 23–28 inequality and, 25–27 nonprofit activity and, 34–36 power differentials and, 28–29 See also democracy Clinton, Bill, 62, 135n28 Colby, D. C., 134n22 Coleman, W. D., 37 community health centers (CHCs), 58, 109–16 competitive bidding, 84–85 Connecticut budget politics in, 83–85 initiation of managed care in, 69–71 Medicaid reform in, 3–5, 14, 64–65 (see also Medicaid managed care; Medicaid Managed Care Council) Connecticut Children’s Health Project (CCHP), 5, 100–101, 107–8 Daley, Richard, 31 Dalleck, Geraldine, 63

152 data availability policy attainability, as factor in assessments of, 6, 39 public talk of Medicaid advocates, as an explanation for, 86–89, 125 Davidson, Stephen, 61 Deficit Reduction Act (DRA) of 2005, 14 deliberation. See citizen participation; democracy democracy benefits of public deliberation in, 7–10, 121–23 deliberative/participatory, 24–25, 28–29 forms of, 23–28 the participatory process, suggestions for improving, 126–30 dental care, 80–83, 85–86 dissent, value of, 9 DSS. See Social Services, Connecticut Department of dual-track health care, elimination of. See mainstreaming Early and Periodic Screening, Diagnostic Treatment (EPSDT) program, 52 economic inequality, 26. See also inequality Eliasoph, N., 16, 131n3 Elster, Jon, 28 embedded social networks, 38 Environmental Protection Agency (EPA), National Drinking Water Advisory Council, 11 “essential” status for providers, 98–100 feasibility. See political feasibility Federally Qualified Health Centers (FQHCs), 58–59 Florida, 14–15 Forand, Aime, 46 Fossett, J. W., 59–60, 134n24 FQHCs. See Federally Qualified Health Centers freedom-of-choice requirement, 52

INDEX Galaskiewicz, J., 32–36, 125 gender, economic inequality and, 26 Georgia, 13 Gilens, Martin, 134n16 Goffman, Erving, 16 Granovetter, M., 38 Gutmann, A., 29 Habermas, J., 25 Harris, F. C., 31 Harris-Lacewell, M. V., 16 Hartford Foundation for Public Giving, 107 Hartford HealthTrack, 101, 107 Hays, R. A., 132n.1 Health, Education, and Welfare (HEW), U.S. Department of, 45, 48–49, 51 Health and Human Services, U.S. Department of, Medicaid Commission, 131–32n8 health care Americans without insurance, 13, 62 history of, 42–43 inequality in, 3–5, 48–49, 51–52 (see also access to health care providers) Medicaid (see Medicaid) medical vendor payments, 44–45, 47 national insurance vs. means-tested public assistance, 45–47 for the poor prior to 1950, 43–44 Health Care Financing Administration, 62 health maintenance organizations (HMOs) beliefs of Connecticut officials regarding, 64–65 in Connecticut, 69–70 (see also Medicaid managed care) creation of community health center-based, 109–16 dentists and, 81, 85–86 hiring of policy network members by commercial, 109 Medicaid reform and, 4–5, 14, 63 HEW. See Health, Education, and Welfare, U.S. Department of

INDEX Hill–Burton Act of 1946, 45, 47 HMOs. See health maintenance organizations Holahan, J., 63 Indiana, 13 inequality as an explanation for public silence, 73–77, 123–24 in health care, 3–5, 48–49, 51–52 (see also access to health care providers) in income and wealth, 26 political participation/ representation and, 25–27 of political voice, 6 power differentials and public deliberation, 28–29 social and economic leads to political, 9, 25–27 Ingram, H. M., 27 institutional factors budgetary climate/politics, 83–85, 124–25 data availability, 6, 39, 86–89, 125 in the development of public policy, 39–40 policy solutions, 6, 39–40, 85–86 political feasibility/climate, 6, 39, 77–83 iron triangles, 36–37 Johnson, Lyndon, 50 Kennedy, John F., 9 Kerr, Robert, 46 Kerr–Mills Act, 46–47 Kingdon, J. W., 39–40, 77 Kletke, P. R., 59–60, 135n27 Knoke, D., 37 Krehbiel, K., 11 lock-in policy, 87–89 Mackie, G., 7 mainstreaming concerns of advocates and participants regarding, 73–74

153 in Connecticut, goal of, 66 dental care, access to, 80–83 explanations for public silence regarding, 89–90 (see also public silence) as a goal of Medicaid, 48–49, 51–52, 58, 61 private assessments of, 71–73 See also access to health care providers managed care in Connecticut (see Medicaid managed care) as cost control, 13–14 implementation of, 62–63 Mansbridge, J. J., 16–17, 23–24, 28–29, 136n8 Maryland, 63 Massachusetts, 14 Mattson, K., 29 McNubbins, Mathew D., 11 Medicaid equal treatment of participants, concerns regarding, 48–49, 56–58 expansions for children and pregnant women, 53–55 goals of, 42–43, 53 importance as a social welfare program, 12–13 Kerr–Mills and, 46 legislation establishing, 47–49 mainstreaming as a goal of (see mainstreaming) managed care demonstration projects, 131n7 nursing home care for older Americans, 55–57 physician fees and participation in the program, 57–61 problems of by the 1990s, 61–62 Reagan-era cutbacks in, 53–54 reform efforts by state governments, 13–15, 62–63 (see also names of states) reform of in Connecticut, 3–5, 14, 64–65 (see also Medicaid managed care) retrenchments of, 49–52

154 Medicaid advocates as able representatives on cost and quality issues, 74–77 collaboration within the network by, 93–94 the contracting regime shift, impact of, 94–98 institutional factors influencing public talk of, 77–89 mainstream access as a concern of (see mainstreaming) oversight body, support for, 100–102 political responses to Medicaid managed care, 98–102 protecting Medicaid providers, costs of, 102–6 silence of, questions regarding, 74 (see also public silence) successes of, 74 Medicaid Managed Care Council (MMCC) community health centers, discussion of, 111–15 cost and quality goals, discussion of, 74–77 creation and organization of, 4–5 dental care, discussion of, 80–83, 86 grievance procedure process, concerns regarding, 87–89 institutional factors influencing discussion by (see institutional factors) new data, impact on public discussion of, 86–89 participant observation of, 17 stakeholder groups represented on, 14 Medicaid managed care (MMC) advisory council for (see Medicaid Managed Care Council) advocates’ political responses to, 98–102 collaboration and interdependence in the policy network prior to the adoption of, 93–94 community health centers’ role in, 109–16

INDEX equitable treatment from HMO plans, concerns regarding, 69–71 mainstream access, private assessments of, 71–73 plan switching, lock-in policy to prevent, 87–89 reform as shift to a competitive contracting regime, implications of, 94–98 structure of, 99 welfare reform and, 77–80 medical care. See health care “medically needy” concept, 47–50 medical vendor payments, 44–45, 47 Medicare, 46–47 Medicare Catastrophic Coverage Act of 1988, 56 methodology, 15–19 analyzing public discussion, 18–19 in-person interviews, 17–18 participant observation, 17 Mills, Wilbur, 46 Mintrom, M., 37–38 Missouri, 15 Mitchell, J. B., 134n24 MMC. See Medicaid managed care National Drinking Water Advisory Council, 11 National Governors Association, 132n8 networks, policy. See policy networks New York, 49–51, 60 Noll, Roger G., 11 nonprofit sector the contracting regime shift, impact of, 94–98 government and, 30–31 public voice of, shift from collaboration to competition and the, 6–7, 125–26 representation of the disadvantaged by, 29–31, 35–36, 128–30 resource dependency and political activity of, 31–36, 93–94 OBRA-81. See Omnibus Budget Reconciliation Act of 1981

155

INDEX Ohio, 15 Old-Age Assistance (OAA), 44–45 Old-Age Survivors Insurance (OASI), 44, 46 Oliver, T. R., 63 Omnibus Budget Reconciliation Act of 1981 (OBRA-81), 53 participation citizen (see citizen participation) suggestions for improving, 126–30 participatory democracy, 24–25. See also democracy Perloff, J. D., 59–60 Personal Responsibility and Work Opportunity Act of 1996, 77 Peterson, J., 60, 134n24 Physician Payment Review Commission, 60 Pitkin, Hanna, 8 policy feedbacks, 38 policy networks bias of Medicaid advocates, perceptions of, 102–6 collaborative relationships and dependency before MMC, 93–94 the contracting regime shift, impact of, 94–98 the Medicaid network, changing relationships within, 91–92, 125–26 policy development and, 36–39 social ties across camps in, 107–16 See also Medicaid advocates; nonprofit sector policy solutions beliefs of coalitions and availability of, 39–40 policy attainability, as factor in assessments of, 6 public talk of Medicaid advocates, as an explanation for, 85–86 political feasibility discussion that goes beyond judgments of, encouraging, 127–28 policy attainability, as factor in assessments of, 6, 39

public talk of Medicaid advocates, as an explanation for, 77–83 poor, the health care before Medicaid for, 42–47 Medicaid and, 52 (see also Medicaid) the nonprofit sector and, 29–31, 35–36 (see also nonprofit sector) political rhetoric of welfare reform regarding, 77–80 poverty, beliefs about the causes of, 43–44 power differentials and participation by, 28–29 representation of, the problem of, 25, 128–30 poorhouses, 43–44 Prague, Edith, 74 public policy institutional factors and the development of, 39–40 (see also institutional factors) policy networks and the development of, 36–39 (see also policy networks) public silence community health centers and, 115–16 explanations for, 6–7, 89–90, 123–26 inequality as an explanation for, 25–29, 73–77, 123–24 (see also inequality) institutional factors as an explanation for (see institutional factors) mainstreaming as an example of (see mainstreaming) the problem of, 7–10, 121–23 question posed regarding, 4–5 responses to the reasons for, 126–30 social ties as an explanation for, 115–16 See also Medicaid advocates Quality Assurance (QA) program, 76 race, economic inequality and, 26 Reagan, Ronald, 53–54

156 Reisinger, A. L., 134n22 representative democracy, 23–24. See also democracy resource dependency, 6, 31–36 Ring, M., 60 Robbins, M. D., 11 Rosenblatt, R. E., 48–49, 51–52, 133n2 Rowland, D., 134–35n25 Royalty, A. B., 134n23 Sabatier, P., 40 Salganicoff, A., 134–35n25 SBHCs. See school-based health centers Schattschneider, E. E., 36 Schlesinger, Arthur, 9 Schneider, A. L., 27 school-based health centers (SBHCs), 81–82 Schwartz, A., 134n22 Simon, W. H., 28 Simonsen, W., 11 Skogstad, G., 37 Social Security Act of 1935, 44 Social Security Amendments of 1962, 30 Social Security Amendments of 1965, 47–49 Social Services, Connecticut Department of (DSS) administration of Medicaid managed care, questioning of representatives regarding, 74–76 budget constraints and competitive bidding, 84–85 commercial HMOs and meeting the goals of Medicaid managed care, 95–96 community health centers, concerns regarding, 111–14

INDEX default plans, designation of, 110 dental services, providers of, 81–82 distrust of by advocates and providers, 101–2 Medicaid managed care, anticipated benefits of, 65 Medicaid managed care, planning of, 4 state governments, Medicaid reform efforts by, 13–15, 62–63. See also names of states Stephens, L., 32–36, 125 Stevens, R. B., 51, 133n11 Stewart McKinney Homelessness Assistance Act, 59 stigmatization, 73 Sunstein, Cass, 8–9 Supplementary Security Income (SSI) program, 51 Taft, Robert, 46 Tennessee, 60, 136n3 Thompson, D., 29 300 percent rule, 134n17 Vanishing Voter Project, 25 Vergari, S., 37–38 Walker, J., 133n.5 wealth, inequality of, 26 Weingast, Barry R., 11 welfare reform, Medicaid managed care and the climate/rhetoric of, 77–80 windows of opportunity, 39–40 Wisconsin, 51 Wright, J. R., 11 Young, Iris, 9, 24